HemoDoc, From Doctor to Patient

The Lufkin DaVita Bleach Murder Trial: The Verdict is in - Guilty of Capital Murder

By Peter Laird, MD

The long awaited trial of Kimberly Saenz is now history with the jury rendering what I thought was a surprising verdict of guilty of capital murder in five cases and aggravated assault in three of five cases. I respect the voice of the people even though I personally disagree with the outcome.  I truly do not believe that the medical evidence proves that any murders or assaults occurred, but the jury has spoken and I respect their efforts in this complex and taxing case.

Jury finds ex-Texas nurse guilty in bleach deaths

LUFKIN, Texas (AP) - A former Texas nurse accused of killing five of her patients and injuring five others by injecting bleach into their kidney dialysis tubing was found guilty of capital murder Friday.

Kimberly Clark Saenz, 38, was fired in April 2008 after a rash of illnesses and deaths at a Lufkin dialysis clinic run by Denver-based health care giant DaVita Inc. She was charged a year later.

Her trial began March 5. Defense lawyers argued that Saenz was being targeted by the clinic's owner for faulty procedures at the facility, including improper water purification. They also suggested that officials at the clinic, about 125 miles northeast of Houston, fabricated evidence against Saenz. Prosecutors described claims Saenz was being set up by her employer as "absolutely ridiculous."

The mother of two now faces life in prison or a death sentence as the case moved to the punishment phase. Prosecutors had said they would seek the death penalty if Saenz was convicted.

Kimberly Saenz awaits the final aspect of this trial, that of sentencing where she could face the death penalty. In the end, God's judgement will be all that matters for each and every one of us. God offers forgiveness and salvation to one and all. My only prayer at this time is that the people of Lufkin Texas can be at peace with the terrible tragedy that has occurred in this small town for all involved. Certainly, there are many who have suffered terribly. It is also my hope that the verdict is true and certain since the potential penalties are harsh.

Hopefully after the penalty phase of the trial is completed, one or some of the jurors will explain how they viewed the evidence of this case that for them appears to have been without any reasonable doubt. It is their right to remain anonymous and silent, but I believe many will wish for a discussion by the jurors at some time in the future.

Once again, the jury has spoken and we must all abide and respect the great personal sacrifice that they took upon themselves to accomplish their duties as citizens of this great nation whether we agree or disagree with their verdict.  May God be with us all in this and all matters as the jury now will decide her fate on life in prison or whether they will apply the death penalty to this case as the case now enters the punishment phase.

Shad Ireland Joins Charity of Choice in Partnership

By Peter Laird, MD

Shad Ireland, the first dialysis patient to complete an Ironman competition is joining Charity of Choice in partnership. To promote this new partnership, Shad will ride in the Bicycling Magazine Open in Philadelphia June 3, 2012. Shad remains active in promoting exercise as a key to improving patients lives on dialysis.

IRONMAN AND DIALYSIS PATIENT SHAD IRELAND PARTNERS WITH CHARITY OF CHOICE. HE IS SCHEDULED TO PARTICIPATE IN THE BICYCLING MAGAZINE OPEN IN PHILADELPHIA

March 27th, 2012 – Minneapolis, MN – Following a grueling week of training Ironman Triathlete and dialysis patient Shad Ireland announces a partnership with Charity of Choice to participate in the Bicycling Magazine Open in Philadelphia on June 3^rd. The dynamic Ireland who is scheduled to return to Ironman triathlons this year will ride in the charity event prior to the professionals taking the course. Ireland and Charity of Choice will work together in 2012 to promote individual and corporate social responsibility and charitable impact at the community level. Ireland stated, “It is an honor to work with Charity of Choice because they provide a unique platform for individuals and athletes to really make a difference for the charity of their choice.”

Charity of Choice gives any individual, business, or charity the ability to set up fundraising pages around any event and for your charity of your choice. Charity of Choice’s CEO is Hunter Ziesing, a health and fitness advocate who is outspoken about health issues when it comes to diet and exercise avoid costly and what can be avoidable health issues.  “Shad’s story to me is not just about defying odds but he sends an important message not only to those affected by disease but to those who can avoid it.”Ziesing’s younger brother was lost his kidneys and spent over three years on dialysis. 

“By riding in the Bicycling Magazine Open in Philadelphia on June 3rd, I hope to inspire people in this country as well as the millions affected by kidney disease across the world to take action and get healthy,” said Ireland. “My biggest goal is to show those who are suffering that anything is possible, no matter the obstacles,” said Ireland.

Shad Ireland has been an inspiration to thousands of dialysis patients in this nation and around the world. He is now entering his thirtieth year of renal replacement therapy. Shad is living his life at its fullest and continues devote much of his energies to inspiring other dialysis patients to engage in an active life. I continue to wish him the best in all that he pursues and we will eagerly await any news of his upcoming events. Shad's story is truly one of inspiration that all dialysis patients should follow in earnest. What he has accomplished in the past points to what he continues to seek and achieve. Once again, we wish Shad the best in his endeavors now and in the future.

The Lufkin DaVita Bleach Murder Trial: Is HemoDoc a Reporter?

By Peter Laird, MD

As the Lufkin DaVita murder trial winds down to its conclusion, it is interesting to follow the news reports as well as all of the comments at the end of most of KTRE's articles. In the last couple of days, there has been a bit of a debate over how accurate my "reporting" of the case has been.  I would like to make a few clarifications. First, I am not a reporter. I am a medical doctor with a blog where I voice my own individual opinions of various issues. If you are looking for both sides of an issue as an unbiased news reporter, you will likely be disappointed since my opinions are mine alone. I do strive for accuracy and presenting the discussion clearly, but in the end, these are my opinions based on an extensive review of the medical issues involved in this case and should not be mistaken for news reports of any kind. Instead of viewing this as a news report, think of it instead as an opinion page since that is exactly what it is. In such I hope it is an informed opinion of not only the Lufkin DaVita murder trial as reported in the news to date, but all the issues that I comment about on HemoDoc.

Defense rests in bleaching deaths Trial

J: Like I said before, unless you have sat through every session and heard evidence/testimony yourself, you really have no idea of the specifics of this trial. The jury will do it's job and whether we like it or not, we have to respect it. As far as hemodoc reporter, reading evidence and hearing/seeing evidence is two different things. I am sure he is a well educated man, however, his accounts of testimony and credibility of witnesses on stand cannot be accurate if he is not in the courtroom. The evidence is detailed, lengthy, scientific, confusing at times. All I am asking is that you respect the job the jury has to do, no matter what the outcome, based on what they have witnessed and not what is reported on this site. 

Another issue is whether I have been in the court room and the answer is no, I have not gone to the Lufkin DaVita courtroom. Instead, I have reviewed the daily news accounts and during the course of the trial, I have limited my opinions only to that which has been publicly reported in the news. I did not during the trial venture beyond news reports to remain within the bounds of the information I already possessed but may not yet have been brought up in court. Obviously, being limited to the information available in the news is not the best way to comment on a trial, but it was all that was available during the trial and it was also all that was appropriate to comment on as well.

That being stated, the news reporting of this case from KTRE and Lufkin Daily News in my opinion was very biased against Kimberly Saenz. In addition, I have added sources to my opinion many of which were not included in the testimony but are well documented in the medical literature and easily found on the internet. I am not sure why that is not a valid manner in which to formulate an opinion of the medical issues discussed in this trial.

Unfortunately, the CDC did not in my opinion complete their task by establishing 3-chlorotyrosine levels in dialysis patients with heart attacks, pneumonia and cardiac arrest or sepsis nor in separating other causes of chlorine sources. Nor did they consider or discover the abnormal chlorine levels in the water that Deaton brought to light. So just sitting in the courtroom didn't give you all of the evidence of this case either. There is much more to this story that can't be told yet in part because of what the judge has disallowed. Hopefully same day that will be known as well.

59th Annual EIS Conference (page 24 of pdf flyer)

DONALD C. MACKEL MEMORIAL AWARD 

Cardiac Events and Deaths in a Dialysis Facility Associated with a HealthcareProvider — Texas, 2008 

Melissa K. Schaefer, C. Lucero, M. Sochaski, R. Kleiman, J. Su, M. Arduino, A.Kallen, M. Schwartz, P. Patel for the Texas Dialysis Investigation Team 

I believe that the CDC has failed especially since they had over four years to prepare for this case. I do believe that Ryan Deaton has been able to elucidate the issues well and I believe that the jury will have the credible information to make an informed decision. I also believe that if Kimberly Saenz is innocent of all charges, then we must ask the question, who is responsible? I believe that the medical evidence provides that answer as well but that will be for the jury to determine. 

For now, it is the jury's time to reflect on the evidence and then speak of their opinions of this case. Their opinion in the conclusion of this whole matter is all that will be relevant anyway. I believe that the trial has brought out the most important information for them to make an informed decision and that is sufficient for the task at hand.  We await that judgement. How the jury will respond is impossible to predict at this time.  There are many on boths sides of the equation hoping for the verdict they believe is correct. Once again, may God be the judge.

The Lufkin DaVita Bleach Murder Trial: What the Defense Must Prove

By Peter Laird, MD

As the defense rests and testimony ends today at the Lufkin DaVita bleach murder trial, comparing the agenda of the defense and the prosecution contrasts what each side must prove to prevail. In many ways, the defense aspects are easier in that the prosecution must prove that the defendant beyond a reasonable shadow of doubt is guilty of the charges as written. The prosecution case was handicapped from the beginning by the lack of any forensic test that is specific for bleach infusion. They didn't exist at the beginning of this trial and I believe it is abundantly clear that as this trial comes to its conclusion soon, it still does not exist.

On the other hand, the defense must only prove that there is a reasonable doubt that the defendant is guilty of all the charges. This is a circumstantial case without any direct physical evidence tying the defendant to the accusations with no fingerprints or DNA evidence reported. Instead, as mentioned in an earlier post, the prosecution case is burdened with the two eye witness accounts that the defendant allegedly infused bleach as they were watching but no direct physicial evidence linked directly to the defendant.

For the defense, the most compelling evidence is the lack of bleach injury on the two autopsies available or in any of the surviving patients. One study that illustrates what the prosecution must overcome is from a recent case report on intentional bleach infusion in a suicide attempt. In this case, the patient placed 20 ml of 5.2% bleach into a 500 ml saline bag and then infused the entire solution. Dr. Schwartz did mention this case in his testimony but he left out a very important aspect of the case report, that of the severe thrombophlebitis that this man developed at the infusion site in his arm:

Venous thrombosis following intravenous injection of household bleach

Abstract

Sodium hypochlorite (NaClO) is used extensively as a disinfectant or bleaching agent. Most studies describe ingestion or inhalation route of this product with rare complication and fatalities. Despite global daily exposures, data about bleach injection is limited. Here we report intentional infusion of 20 mL, sodium hypochlorite 5% diluted in 500 mL normal saline 1.5 h prior admission. Clinical manifestation included local pain and edema. There were no laboratory abnormalities in the patient. Doppler sonography revealed thrombosis in superficial (antecubital and basilic) veins. Limb elevation, warm compress, and ibuprofen relived pain and edema after 3 days

Case report 

 A 30-year-old previously physically healthy man was admitted to the emergency department (body- weight, 75 kg). He attempted suicide by infusion of 500 mL normal saline serum containing 20 mL household bleach (sodium hypochlorite 5%) into right cubital vein with intravenous (IV) line, one and a half hours before admission. He had a history of schizophrenia since 10 years and this was his first suicide attempt. On arrival, the patient was hemodynamically stable. Oral temperature was 37.5􏰁 C (99.5􏰁 F), pulse rate 103 beats per minute with a normal rhythm, blood pressure 135/80 mm Hg, and his respiratory rate was 18 breaths/min with no abnormal breath sounds. The abdomen was soft and flat with normal bowel sounds. The initial oxygen saturation was 95% (in room air). He was alert, awake, and in no apparent distress. He complained of painful swelling in his right upper extremity. In clinical examination, the arm was painful and relatively swollen. 

Dr. Gruszecki noted the lack of physical evidence, the lack of direct forensic evidence and the lack of any substantiated evidence of hemolysis or hyperkalemia in these patients in her reported testimony. We know from the medical literature that bleach reacts immediately with all non-epithelialized tissues. In several cases, the alleged onset of symptoms were up to two hours after the alleged infusion of bleach which is not medically sound or logical in my opinion.

The defense in this case did more than just dispute the prosecution allegations at the patient level, the defense found many serious procedural and professional deficiencies at the Lufkin DaVita facility that raise the case of reasonable doubt. Finding significantly elevated chlorine levels in treated water used for dialysate is a potential answer to the elevated 3-chlorotyrosine levels. The test itself cannot delineate between the two. The fallacy of this thinking is that they appear in my opinion to have put the cart before the horse and assumed her guilt as they built their case instead of seeking all avenues of investigation first before drawing any conclusions. In addition, they had samples from two and five days after the last dialysis which is enough time for the 3-chlorotyrosine levels to fall dramatically as noted in more than one of the alleged victims rendering 3-chlorotyrosine a poor marker of bleach with a very short window to apply its discovery.

The CDC testimony further failed to identify many of the practice variations that has been revealed in this trial such as running the bleach cycle in the dialysis machine between the first and second shift, the fact that the bleach in the blood lines had to be placed after the machine had stopped from Dr. Neidigh's testimony, as well as the widely used syringes to measure bleach for cleaning the machines noted by at least two former employees.

In addition, the defense may have added another layer of reasonable doubt by uncovering the many DaVita actions that bring into question whether they have altered, destroyed or contaminated much of the physical evidence. In the final analysis, it quickly became evident that there is no incontrovertible evidence that any murder or assualt had taken place with any of the patients in this unit. If the prosecution does not prove that the patients were absolutely murdered or assualted with bleach, the eye witness testimony and circumstantial evidence is rendered moot.

This trial shall always generate doubt and uncertainty as to what truly happened at the Lufkin DaVita facility, but there is also much that is now openly revealed by the reported testimony. It remains a complex case where the verdict will remain in doubt until the jury speaks and perhaps even after they speak. Viewing the news and comments, there appears to be a diverse opinion about this case in the public.

The Lufkin DaVita Bleach Murder Trial: What Killed These Patients?

By Peter Laird, MD

The defense has rested in this controversial trial and the prosecution is finishing this morning with its last remaining rebuttal witnesses prior to closing arguments. The witnesses and the evidence is now a matter of record, yet few in the public have heard the evidence presented to the jury already.

In the last week, the defense presented three expert medical witnesses testifying on their independent review of the facts. Dr. Jonathan Neidigh evaluated the physical evidence of bleach and the 3-chlorotyrosine levels found in several, but not all of the patients. Dr. Neidigh testified that in his opinion, the known chlorine breakthrough found on an improperly functioning carbon filtration tank is the most likely explanation of the elevated levels of 3-chlorotyrosine which infused dialysate with chlorine levels fifteen times higher than allowed.

Dr. Neidigh further noted that even those highly positive for 3-chlorotyrosine showed a rapid decline within two days of not dialyzing at the Lufkin DaVita unit. This is even more important when considering the alleged controls for this test from the same dialysis unit didn't have their blood tested until two and five days after their last dialysis at Lufkin DaVita rendering these so called controls meaningless as reported in the news.

Dr. Michael Germain and Dr. Amy Gruszecki completed the defense response to this trial. Dr. Gruszeki is a Pathologist who routinely testifies for the state of Texas and has only testified for the defense in four prior cases. Dr. Gruszecki found no evidence of bleach infusion in any of the patients and noted several obvious explanations for the cardiac events as well as explanations for many of the abnormal labs discussed in this case.  

One case in particular illustrates the illogical conclusions that the prosecution has twisted to fit their preconceived accusations against the defendant. Graciela Castaneda is the only cardiac arrest patient at Lufkin DaVita that survived and later testified against Kimberly Saenz in this proceeding. Throughout the trial, her elevated 3-chlorotyrosine levels coupled with the highest levels of LDH in this group has been touted by the prosecution as direct evidence of bleach infusion. However, I believe that there is a different story.

Dr. Sochaski notes that Castaneda had the highest 3-chlorotyrosine levels (70 times higher than “natural”) and Dr. Schwartz testified that the highest LDH of 2150 was due to hemolysis alone from bleach infusion. In addition, for the defense, none of her blood lines tested positive for any bleach residues.  Reviewing her case in detail, I believe that there is an alternative explanation for the elevated LDH and an absence of corroborating evidence for hemolysis that is objectively documented in her medical record. 

2 Experts testify about computers, bleach poisoning

The lone survivor out of the six, Graciela Castaneda, went into cardiac arrest at 8 a.m. April 16, 2008, and was given a shot of epinephrine at 8:08 a.m., Tortorice said. Twenty minutes later, her potassium level was normal but her level of LDH, a marker for hemolysis, was extremely elevated at 2150. Days earlier her LDH was within normal limits at 219, Tortorice said. Normal is considered 140 to 280.

Whether the patient actually choked on her gum is not confirmed by the paramedic report or nursing note although there are several second hand references to gum being removed by paramedics during the code, but it was not documented by the paramedics or the nurse giving report as evidenced by the rebuttal witnesses today as reported in KTRE (here). In many ways the gum issue may be nothing more than a red herring that does not explain the labs completely nor was there any first hand evidence that it caused this event.

There is no need to consider an alternative explanation of the elevated LDH when acute heart failure secondary to possible myocardial stunning, coronary insufficiency, pneumonia and transient congested liver explain the elevated LDH much better.

I believe that the dialysis nurses may not have realized her possible decompensated state prior to initiating dialysis that morning manifested by an unrecognized pneumonia. What was absent  in this case was any confirmatory evidence of hemolysis beyond the elevated LDH which is best explained by the confluence of issues listed above.  Specifically, the Total bilirubin in this patient was normal which essentially excludes the LDH as being from hemolysis since we would expect an LDH from hemolysis alone to also increase the bilirubin levels as well. 

In addition, the total CPK elevated which would have been consistent with the prolonged CPR causing local skeletal muscle trauma which is also a documented cause of elevations of LDH. Her potassium on initial evaluation in the ER was 3.3. Dr. Schwartz believed that the dose of EPI given by the paramedics would have “masked” the hyperkalemia from his alleged bleach infusion theory. However, prior studies on EPI and other agents in dialysis patients showed only a very modest effect of EPI on potassium levels that is of short duration and plateaus when the receptors are fully occupied by the epinephrine in ACLS doses. 

One aspect that the defense has targeted is the markedly elevated ultrafiltration rates in these patients. During the last several years, multiple studies have shown a correlation between elevated ultrafiltration rates higher than 10 ml/h/kg and increased mortality as Deaton pointed out in court. Castaneda's value approached 20 ml/hr/kg, nearly double the recommended rate. The surprising finding in Deaton's cross examination of this rebuttal witness is that eight of the ten alleged victims all had excessively high ultrafiltration rates with no evidence of hemolysis:

Defense rests in bleaching deaths trial

Deaton then asked the witness about the rate of which fluid is removed during dialysis treatment, called ultrafiltration. According to an article, published in the 2011 International Society of Nephrology, which he references, Deaton says ultra filtration rates of 10 to 13 are high and can be unsafe for dialysis patients. He further says rates of 13 and above is too high for every patient.

"Your risk for cardiac arrest at an ultra filtration rate of 15 almost doubles, and it goes up from there," said Deaton referring to the same article on ultra filtration.

Deaton pointed out that chart records show Marva Rhone's ultra filtration rate (UFR) was 13.8, Carolyn Risinger's was 20.8, and Debra Oates' was 11.8. . . 

. . . Deaton then pointed out to Crumb that from the calculations he's conducted, the DaVita patients listed in the indictment had high UFR's.

"Every single one of Dr. Nazeer's patients had ultra filtration rates over the rate of 10," said Deaton.

Deaton said that the jurors in the trial know more about medical histories, at this point, than the witness. The witness agreed this assertion was true as well as admitted that he did not review witness statements.

The witness testified that he read nephrology articles on a regular basis, although he had not read the two articles Deaton referenced while Crumb was on the stand.

In cross-examination, the witness argued that the process of ultra filtration may be a factor in patient deaths, but the amount of fluid needed to flush out a patient's body could also be a factor.

"The ultra filtration may be a factor," said Crumb.  "The patient that needs the most ultra filtration needs the most fluid."

Crumb argued that there was not extra fluid found in the patients' bodies. He also told jurors he has been in the process of dialysis for the past 40 years.

When considering the evidence in this case, it will be important for the jury to consider that if the prosecution cannot prove that any murders occurred, which in my opinion they have failed to establish, then all of the circumstantial evidence that the prosecution amassed is meaningless. The expert defense witnesses have testified under oath by their own independent evaluations that no murders or assaults occurred but that the practices in this dialysis unit directly contributed to this cluster of deaths and cardiac events. 

I believe it is time not only for the jury to hear all the truth, but the public as well now that all of the witnesses have spoken that will speak in this case and is now part of the public record for all to review if they should desire that opportunity. The entire trial has been video recorded in the court room as well which is also part of the public record of this case. The actual cause of death many times is much harder to discern but often you can exclude specific causes. I believe that the defense has offered evidence against bleach infusion and perhaps contributing factors as well related to this clinic's dialysis practices.

The prosecution expert witnesses, especially Dr. Schwartz from the CDC, have in my opinion over looked well documented evidence of alternative etiologies of these arrests that contradict their assumptions that the only etiology has to be bleach infusion. The method we use to explain abnormal labs is called a differential diagnosis.  That is a basic tool we use throughout medical practice in evaluating symptoms and test results.

An elevated LDH alone is not diagnostic of hemolysis or bleach infusion when in fact, LDH is present throughout the body and not just in blood cells. Any damage to cells throughout the body can result in elevated LDH levels. Since this is so central to the case, I have wondered why no one fractionated the LDH to see which subgroup was elevated. That would have given very important and perhaps exculpatory evidence that is now likely too late to retrieve. These are basic medical student level evaluations of LDH and other labs that I never heard mentioned in any news report. That remains a puzzle to me on how the CDC approached this case.

The Lufkin DaVita Bleach Murder Trial: Is There a DaVita Conspiracy?

By Peter Laird, MD

Throughout the course of this trial, Ryan Deaton has repeated alleged that Kimberly Saenz is a spagegoat for what has gone wrong at this Lufkin DaVita unit and in addition that DaVita has tampered with evidence and hindered the police investigation. Certainly, DaVita did admit to opening the sharps containers prior to calling the police which does bring into question evidence tampering from their own admissions. When we also consider the eight hour delay before calling the police, the eighteen day delay before police were allegedly allowed to speak to DaVita employees after DaVita had conducted it's own internal investigation which the judge did not allow into evidence, then there are many aspects of this case that lend itself to conspiracy theories.

In addition, the carbon "ghost tanks" without proper documentation on why DaVita changed them, the allegation that one of the supervisors would not go down alone, and the janitor's statements also not allowed into testimony that she threw away so many bags of shredded documents the day the police were called that she could not shut the garbage bin all points to a possible DaVita conspiracy to cover-up the real causes of these events. However the most direct evidence that there may have been a cover-up came from the extensive and complex work by Dr. Jonathan Neidigh from Loma Linda University where his research led him to the astounding conclusion that the bleach traces found in some of the bloodlines had to be placed there after the machine was stopped:

Witness says clinic was seeking scapegoat

Spending most of the afternoon on the stand, California-based biochemist Dr. Jonathan Neidigh testified he believes patient lines tested positive for chlorine because it was put there after the fact. Because of the rate at which blood flows through the lines, Neidigh said he believes the blood would have washed away traces of chlorine — more proof DaVita officials planted evidence, according to Deaton.

I don't believe that there will ever be any "smoking gun" that confirms a direct conspiracy at DaVita. At present it is impossible to know whether individual actions either by omissions or commissions may be responsible for these events. It is clear, that DaVita is guilty of one thing, that of not avoiding the appearance of evil as the Bible commands those that follow God's Holy Word.

I Thessalonians 5:22   Abstain from all appearance of evil. 

DaVita, despite all of its high paid lawyers who have haunted this investigation since the beginning and all of its P.R. efforts, still in the end analysis has not avoided all appearances of evil in my opinion. The trial itself takes on a new perspective following the connections of the  the CDC and the Hamner Institute which is also in close partnership with the University of North Carolina (here and here) which on the surface is perfectly reasonable as the N.C. research triangle is one of the most highly technical research centers in the nation. However, understanding that a prominent DaVita board member is also the president of the UNC medical school does not sit well with many that are aware of this "open secret" and how inappropriate those associations appear in a case where the Hamner Institute and the CDC play such a central role for the prosecution in a case where DaVita may be culpable for the events at this unit.

In the final analysis, the issue of whether there is or isn't a DaVita conspiracy in my opinion is irrelevant to the facts of the case that show clear evidence of the defendant's innocence as we have seen reported to date in the news. The distraction of the various alleged DaVita "appearances of evil" will probably not be the most important evidence for the jury to consider nor is there any evidence to connect the different elements to any viable conspiracy theory.

There appears to be a complete lack of evidence for bleach infusion outside of the research test, 3-chlorotyrosine, and that remains the most important evidence for the jury to consider. 3-chlorotyrosine could have been increased from the contaminated water with high levels of chlorine that should have been removed by properly functioning carbon filters.

I believe that if the jury returns a not guilty verdict, the testimony of the expert medical witnesses for the defense will be the final arbiter of justice in this case. However, no matter the outcome of this case, DaVita in my opinion has greatly tarnished its already tainted image from the other legal problems that the company is plagued with. Avoiding all appearance of evil may be something that DaVita considers as it moves forward as this case draws to a close. Abandoning reuse would be a great first step in that direction in my opinion as a public gesture of good will.

The Lufkin DaVita Bleach Murder Trial: Countering the CDC Testimony

By Peter Laird, MD

The Lufkin DaVita bleach murder trial will enter its final phase as the defense provides expert witnesses on the clinical aspects of the individual cases. The CDC presented evidence last week by Michael Schwartz that surely will be contested. According to news reports, Dr. Schwartz alleged that 100% of bleach would have been removed by one pass through the artificial kidney which completely ignores the fractional solute removal that renal dialysis is based upon. Diffusion of solutes is not nearly 100% efficient in four hours of dialysis let alone one pass through the system.

Dr. Schwartz assertion that all of the bleach would clear in only one pass through the machine as noted in news reports and thus serving as his explanation for why the autopsies in the two patients showed no evidence of bleach infusion is beyond absurd in my opinion. The allegation it would be removed is in my opinion farcical and not defensible by any evidence based medical literature. If this is the level of CDC evidence, then the prosecution may have built their entire case on a house of cards.

In addition, Dr. Schwartz reportedly alleged that epinephrine would mask  elevated potassium levels from hemolyzed blood from bleach. Studies likewise do not show epinephrine having that type of ability. Epinephrine does drive potassium into the cells, but it is a very modest and only temporary affect. In my opinion, I  believe that Dr. Schwartz did not testify factually on these two issues and perhaps more that cannot stand up to the scrutiny of evidence based medicine. 

Witness describes Yahoo! search for 'bleach poisoning'

Schwartz said that he found the autopsies to be uninformative. The autopsies weren't able to effectively explain what Schwartz says his research on the effects of sodium hydrochloride have taught him.

"Epinephrine was given to all the cardiac arrest victims between the time they were at the Lufkin Davita Clinic and the time they got to the emergency room," said Schwartz.

Schwartz said these epinephrine were meant to restart patients' hearts, but perhaps had an adverse effect because of the presence of sodium hydrochloride.

Schwartz talked about the way bleach probably came into contact with patients.

"It went into the dialysis bath, it didn't go into the bloodstream of the patients," said Schwartz.

The most pressing issue is that of the elevated 3-chlorotyrosine levels that the CDC has paraded before the world as proof of bleach infusion. However, the defense witness testifying today, Dr. Jonathan Niedigh of Loma Linda university, countered many of the tests performed by the CDC on the alleged victims bloodlines. One of the most important cases is that of Graciela Castaneda, an alleged victim that the CDC heralded as absolute proof of bleach infusion by the highest tested 3-chlorotyrosine levels, yet they have a problem, the CDC was not able to find any bleach residue in her bloodlines.

Witness in bleach trial says supervisor said 'I will not go down for this'

Deaton directed his attention to asking the witness about the bloodline of Graciela Castenada.

"This is one of the bloodlines in his reports, he did not list any positive evidence for bleach," said Neidigh.

The witness testified that Jackson was very thorough in looking at multiple sites on the bloodlines for bleach. He stated Jackson used several methods to test each blood line. In Castenada's blood, there was a positive finding for a bleach or chlorine content, but the bloodline did not reveal any content of bleach or chlorine.

"The logical conclusion was that bleach or chlorine did not come through the bloodline," said Neidigh.

The witness concluded that the bleach content found in blood would have had to most likely come through natural causes. The witness said this appeared to be the case for a couple of the patients tested.

The prosecution case has centered on the allegations of two elderly and potentially physicially compromised "eye witnesses" and the defense alleges it has the medical records where there is a paucity of evidence to date supporting bleach infusion manifested by hemolysis. For the eye witness accounts to be meaningful, explicit evidence of a murder must be found. For the prosecution, it doesn't appear that they ever found the smoking gun.

As the defense presents its final expert witnesses tomorrow, the unknown factor of this entire case is how will the jury adsorb difficult medical records, complex technical research evidence, and evidence that employees at DaVita may have acted inappropriately by delaying notification to the police, contaminating evidence, losing evidence, and potential internal supervisory misconduct according to the witness testimony today on top of clear evidence pointing to failures to adhere to the standards of dialysis care expected by this DaVita unit such as running the bleach cycle between the first and second shift as one employee testified recently.

How the jury will pull this entire case together remains the greatest mystery to both sides. I believe the complexity of this case could easily overwhelm the members of the jury. How the defense presents its case tomorrow in many ways may be the most important determinant of the final outcome. I look forward to hearing the other side of the story tomorrow as we will see in the news reports from KTRE and Lufkin Daily News. I suspect that the final day of testimony will be filled with surprises few could imagine in the midst of the prosecution case just one week ago today as Dr. Schwartz confidently declared Kimberly Saenz guilty. Since Ryan Deaton began his defense case, the news from the court room nearly every day is filled with revelation after revelation I had never heard about this case. 

My only prayer is that the truth of this incredible saga may be fully known, and not just by a reasonable doubt without a satisfactory conclusion to anyone. I believe that the truth shall prevail. Those that have died and suffered at this DaVita unit deserve no less. After all, their story is the real story of this tragedy. I believe that there will be many answers for all that have followed this case over the last four years and especially for the survivors and the families of all involved. May God be the final judge in all things.

The Lufkin DaVita Bleach Murder Trial: Judge Disallows Testimony of Janitor who Disposed of Shredded DaVita Documents

By Peter Laird, MD

Some of the most explosive testimony from defense witnesses rocked the Lufkin courthouse today as reported in news reports. The testimony ranged from accusations that one of the nurses testifying against the defendant harassed the witness and her husband and even sent a clear liquid in a syringe one time. Another witness corroborated the defense story of using syringes to measure bleach as well as placing bleach towelettes for cleaning in areas where the bleach could drip onto blood lines and into the sharps box. One of those that wanted to testify today presented her testimony without the jury present. The judge ruled her testimony irrelevant to the case and she was dismissed. I wonder how many people believe that the following testimony is irrelevant:

Ex-DaVita employee says others put bleach in syringes

The defense called upon Vicky Sheffer, who testified that, she worked, cleaning the Lufkin DaVita Clinic.

She said she cleaned the clinic on April 28, the night the clinic closed.

"I personally threw away three bags myself," said Sheffer "It was enough that we could not shut the lids."

She said it was obvious to tell the bags had shredded paper because the shreds were coming out the top of the bags. Also, the bags, the witness testified, were not heavy.

"It was very dirty," said Sheffer.

She testified that there was human feces on the floor, some machines were leaking and there was evidence of urine in some of the chairs.

"Sometimes it would be sticky stuff, but majority, it was white," said Sheffer as she described what she saw during cleaning.

Deaton asked Sheffer about finding blood and bloodlines at the facility.

"Blood from the front of the lobby all the way to the back, drops of blood. I did find IVs in the sink," said Sheffer.

Sheffer said she would have to pick up bleach bottles off the floor and measuring cups, which could be missing or on the floor as well. She said if she found blood on the chairs, they weren't made to clean it, so it would be left there. Sheffer said she cleaned the facility once a day.

I believe it is important for the jury to hear the truth and the whole truth of this case. Time after time the judge has ruled potentially important defense evidence not admissible such as not allowing the internal DaVita investigation stating it was irrelevant and likewise not allowing the potentially derogatory Lufkin DaVita state inspection that found serious excursions from acceptable medical practice.

Ultimately, in the end, if the defendant is convicted and given a capital punishment sentence, I believe that there may be several restrictive rulings that could lead to a new trial on appeal. I also personally believe that there is overwhelming evidence exhonorating Kimberly Saenz of all these charges and abundant evidence in my opinion to support speculation and perhaps more than speculation of destruction of evidence by DaVita employees as the defense claims. After all, the janitor knows what she put into the trash bins the day the clinic closed and testifies that they were shredded documents and so many that they couldn't close the lid on the trash bin. How the jury will see this case will remain unknown until they have their moment to reveal it to the public.

The Lufkin DaVita Bleach Murder Trial: Carol Risinger - The Mystery Victim With No Evidence

By Peter Laird, MD

The defense continues to establish evidence that Kimberly Saenz was not observed infusing bleach with two of the alleged victims. Interestingly, the prosecution has absolutely no physical evidence whatsoever on one of the alleged ten victims. Carolyn Risinger according to testimony on Monday from her husband was never informed of any alleged bleach infusion nor that they should immediately go to the Emergency Room as did Ms. Rhone. In such, we have no blood tests at all from the alleged witnessed attack against Mrs. Risinger on April 28, 2008. In addition, the physical evidence with the dialysis machine was likewise discarded allegedly by the DaVita staff accidentally. 

Former co-worker describes attitude of capital murder suspect

The witness testified that he could not recall who exactly stripped the bloodlines off of Rhone's machine. Deaton pointed out that Sockwell told Abbott that he stripped the machines himself.

"Do you know why Ms. Risinger's bloodlines were not saved?" said Deaton.

"No, I do not," said the witness.

Deaton asked where Ms. Risinger's bloodlines went after her episode.

"They were probably in a red biohazard bag in a trash can," said the witness.

This is just one episode of the DaVita bleach murder case that defies absurdity in my opinion. In other words, the prosecution is trying the defendant for an alleged attack on Mrs. Risinger that she and her husband had no awareness, nor is there any physical evidence with blood tests or even the dialysis blood tubing and kidney. The facts that this physical evidence appears to have been handled with so little regard should caution those that have confidence in the other physical evidence of the other alleged cases. One aspect that further defies credulity is the fact that apparently no one at this DaVita unit can think of any reason why bleach would be found in a sharps box except that the defendant placed it there allegedly. 

Former co-worker describes attitude of capital murder suspect

"Do you know of any reason bleach could get into a sharps container?"

The witness replied that he could not think of a reason for that.

"What do you put in sharps containers?" said Herrington.

"Needles, syringes, and medication bottles that you might have chair side," said the witness.

Herrington also pointed out that in an interview, Sockwell did not mention picking up Ms. Rhone's sharps containers until after she was sick. Herrington concluded that the witness picked up the container after the episode.

After dialyzing in over ten different dialysis units in at least seven different states, the answer in my mind is quite academic. It is a very common practice to wring out bleach towelettes into sinks, trash cans and yes, sharps containers if that is the closest place to wring out a towelette when cleaning the dialysis station. It is something that I have personally done myself while doing my own self care dialysis for nearly two years. Apparently, no one at the Lufkin DaVita dialysis unit ever saw that practice. I know I have.

The trial continues the rest of this week. As we consider the case, I can readily exclude a guilty verdict in my opinion for Mrs. Risinger based on absolutely no forensic proof with no evidence whatsoever other than an alleged eyewitness account that is disputed by competent staff and DaVita observers present in the clinic that day. For a capital murder case, I would expect more explicit proof that I have seen in the news reports to date.

The Lufkin DaVita Bleach Murder Trial: The Evidence the Prosecution Didn't Present

By Peter Laird, MD

Having reviewed the majority of the case prior to the onset of the trial, there were many aspects that I had expected to see and evaluate further once the trial began.  However, after two weeks of testimony from the prosecution which has now rested its case, I am surprised at the many aspects of this case that the prosecution did not present that may have an impact on the entire case. These include the DaVita investigation conducted independently and prior to the full police investigation; the epidemiology study of the CDC investigators that won the 2009 Donald C. Mackel Award for the study: Cardiac Events and Deaths in a Dialysis Facility Associated with a Healthcare Provider —  Texas, 2008; autopsies for three of the five alleged murder victims and the lack of any hematology expert opinions on the issue of hemolysis.

The story inside of this murder case is that DaVita conducted it's own independent study on the events of their Lufkin DaVita dialysis unit. The news reports that Deaton has brought this up in court more than once. I suspect that many are interested in exactly what DaVita administrators related to their corporate headquarters on this entire case. This report and internal investigation is even more important given the eighteen day delay by the lead Lufkin detective before he conducted interviews with the DaVita Lufkin employees.

Week 2 of testimony in trial of former nurse accused of injecting dialysis patients with bleach

Deaton also argued that DaVita officials would not let police interview employees until 18 days after the initial investigation.

And, Abbott said the clinic was not avoiding police interviews. He claimed he didn't conduct the interviews immediately because he didn't request them immediately.

The defense further notes the elevated chlorine levels fifteen times higher than the allowable limits. The defense attorney did question DaVita personnel on the so called "ghost" carbon filters that DaVita changed shortly after the clinic closed for the criminal investigation. Nevertheless, the prosecution did not present any of the evidence gathered by DaVita in their own investigation and that is a large amount of evidence I would personally wish to review. What was the reason that prompted this company to change its carbon tanks that are responsible for removing chlorine from the water system?

Coworker testifies in day eight of capital murder trial

Deaton questioned Kaparek about the lack of documentation for new carbon tanks — used to remove bleach from water before it is used in dialysis — at the Lufkin clinic. The defense attorney asked Kaparek if he wasn’t “the top dog” for DaVita in his field; Kaparek responded that he doesn’t think of himself as a dog, but that he is the top person in his section of the company, and that he did not believe the “ghost tanks,” as Deaton called them, were a cause of any problems in the water treatment process.

Another missing study is the epidemiology study by the CDC headed by Dr. Melissa Schaefer looking at all of the adverse events for several months prior to April 2008 and in depth detailed evaluation of all of the adverse events in the dialysis unit during the month of April.

59th Annual EIS Conference (page 24 of pdf flyer)

DONALD C. MACKEL MEMORIAL AWARD 

Cardiac Events and Deaths in a Dialysis Facility Associated with a Healthcare Provider — Texas, 2008 

Melissa K. Schaefer, C. Lucero, M. Sochaski, R. Kleiman, J. Su, M. Arduino, A. Kallen, M. Schwartz, P. Patel for the Texas Dialysis Investigation Team 

These additional cases in the month of April appear to be outside of the confines of what will be allowed for the jury to hear as evidenced by an apparently sustained objection by the prosecution when the defense attorney tried to introduce this case for discussion on the first day of the defense case:

Defense takes its turn in bleaching deaths trial

Referring back to April 7, Deaton began asking the witness if she knew a Maria Lopez, but was interrupted by Herrington's objection. Deaton asked if test strips were always accurate and if the witness ever remembered a situation when it hadn't been accurate.

The most glaring aspect of the entire prosecution's case in my opinion is that there were only two autopsies conducted on the five alleged murder victims. Of these two autopsies, one of the principle CDC investigators who testified last week, Dr. Michael Schwartz stated that the autopsies did not confirm his suspicians of bleach infusion.

Witness descibes Yahoo! search for 'bleach poisoning'

"I reviewed an autopsy on Cora Bryant and Garlin Kelley," said Schwartz.

Schwartz said that he found the autopsies to be uninformative. The autopsies weren't able to effectively explain what Schwartz says his research on the effects of sodium hydrochloride have taught him.

Thus, for a murder trial, we have three alleged victims without an autopsy for conclusive forensic evidence gathering and two autopsies where the chief CDC witness for the prosecution could not find evidence of bleach infusion on these autopsies.  For a capital murder case, in my opinion, I find this unacceptable. I would expect more conclusive evidence at autopsy that a murder did occur.

According to Dr. Schwartz, the completed autopsies of two of the victims did not confirm the prosecution theories. That is the ultimate difficulty of this circumstantial case. The prosecution has a large circus of witnesses all stating that a murder occurred, but looking at the alleged victims, where is the evidence that a murder did occur? This glaring discrepancy would have loomed even larger had the prosecution introduced the CDC investigation report by Dr. Schaefer as part of their alleged evidence and allowing the defense an opportunity to discuss the other cases outside of the alleged victims she is accused of harming which the judge would not allow Deaton to explore as noted in one news report previously.

Lastly, I had thought that the central aspect of bleach induced hemolysis would include expert testimony from, of course, a well respected hematologist. However, the prosecution included evidence from the treating nephrologist, a toxicologist, a research laboratory investigator, but not from a hematologist expert in the interpretation of laboratory evaluations for hemolysis. The expected results of bleach infusion are hemolysis accompanied by elevated levels of potassium leading to an arrhythmic cardiac event.  

Establishing conclusively that hemolysis did occur as evidenced at autopsy and by clinical laboratory measures should have been a key part of the prosecution's expert testimony in my opinion. Instead, not one hematology expert was called to testify that I am aware of by reading the news reports daily since the trial began. Perhaps the lack of documentation of hyperkalemia (elevated potassium) and the soft, nonspecific reliance on elevated LDH levels alone would have been difficult for a hematologist to conclusively state hemolysis had occurred. Diagnosis hemolysis is specific and many of the usual steps on diagnosing hemolysis have not been reported in any news reports leaving me to wonder how the high LDH levels were confirmed as only from hemolysis. 

I also did not see any evidence presented in the news of the DaVita staff that after hearing of the allegation of bleach infusion, that they performed a bedside test for hemolysis which is standard protocol whenever hemolysis is suspected. The suspicion of hemolysis could have been answered directly by performing a very simple "pink test" immediately for both alleged victims of bleach infusion on April 28, 2008. Instead, the physician sent one of the alleged victims that day to the ER where he allegedly "diagnosed" hemolysis by the nonspecific LDH levels.

An immediate bedside evaluation is mandatory whenever there is any suspicion of hemolysis. A small venous sample is collected while the patient is on the machine and then spun down. Pink or cherry colored red plasma indicates direct evidence of active hemolysis with free hemoglobin in the spun plasma. Once again, this is the standard of care whenever their is reasonable suspician of hemolysis. The accusation of bleach infusion is definitely a reasonable suspician for hemolysis and should have been the first test performed instead of breaking into sharps conatainers and possibly contaminating valuable evidence.

Multistate outbreak of hemolysis in hemodialysis patients traced to faulty blood tubing sets

Hemolysis was defined as discolored, pink serum visualized in a spun serum sample (that is, "pink test") collected from the dialysis patient or noted by the hematology clinical laboratory personnel. 

To date, these are the most glaring discrepancies of this case of testimony that I would have expected from reviewing the news reports of the prosecution case presented during the first ten days of the trial. If the jury is to be able to draw conclusions on a capital murder case, in my opinion, they should hear not only the truth, but the whole truth as well. I guess not being a lawyer, perhaps the reasons the judge ruled in this manner on some of the evidence are beyond my limited understanding of the law. Perhaps he has simply been too restrictive, perhaps it was appropriate. If convicted, the appeals court will likely decide those issues.