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.

Comments

[previous Davita RN--Los Angeles area]

I remember our unit (UCLA) around 2008, having to absorb several patients from the Beverley Hills Davita unit. Other nearby Los Angeles units absorbed the rest---due to a "bleach exposure" where several patients had become ill during dialysis---we were not told much, only that the Beverley Hills unit would be closed until things were corrected. I do not know the outcome, and cannot find anything online about this. Davita remains very quiet, when these events occur. They should have records, though. There was discussion about "the loop" in the wall (where the water runs through) not being properly flushed out before dialyzing patients.

[roberta mikles]

Davita RN, thank you for sharing -You might be able to obtain a copy of the facility's inspection by contacting the California Dept of Public Health in the Los Angeles area-- you can request a copy!

I have copies of surveys conducted in California dating back to 2003. If you know the address of the facility and correct name, I can see if I have a copy.. Our website www.qualitysafepatientcare.com has posted surveys from 09-11 for California.
Roberta Mikles BA RN

[roberta mikles]

You can find 'some' information on the Davita Beverly Hills unit ---
http://projects.propublica.org/dialysis/facilities/52599 This document shows care that, in my opinion, was not good --

DAVITA-BEVERLY HILLS DIALYSIS CENTER, Beverly Hills, Calif.

From 2006-2008, the facility had 34% higher than expected hospitalizations -- their days in hospital was for same period was 62% HIGHER than expected
http://propublica.s3.amazonaws.com/assets/dialysis/facility-reports/CA/2009/CA_052599_2009.pdf

In 2008 the facility's death %age due to infections was 32%. 25 patients died and 32% were a result of infection 36% were result of cardiac causes

Hence, so what if 96% OF THEIR patients had a URR over 65?

opinions of Roberta Mikles