Medical Experts Opinion

Erik Messamore, MD, PhD
Consultant specialist in psychiatry and psychopharmacolgy emessamore@gmail.com

27 April 2015

 

Michael Micolo’s defense attorney, Chelsea Peterson, requested that I render an opinion about the mental status of Michael Micolo around the time of May 17, 2014. It is clear that Mr. Micolo's behaviors at that time were decidedly abnormal. His mental status at the time represented substantial departures from both his own baseline and from societal norms. Descriptions of his behavior on 5/17/14 are strongly suggestive of delirium. Delirium is an abnormal mental state characterized by: lack of awareness of surroundings; memory impairment; altered perceptions of reality; erratic behaviors; alteration between extremes of levels of consciousness, ranging from sedation or stupor to agitation and combativeness. Delirium can arise from medical illnesses which perturb normal physiology. Medical assessment conducted on the morning of 5/17/14, at the time when he was still in a state of delirium, are remarkable for several reasons.First, a urine drug screen revealed only the presence of marijuana. Mr. Micolo hadbeen a regular marijuana user prior to 5/17/14 and had apparently never suffered delirium from it. Though intoxication with other drugs has been alleged, the fact is that no intoxicants other than marijuana were found during his evaluation, and marijuana is unlikely to have caused the severe mental status alterations that occurred that day. Second, Emergency Department treatment of Mr. Micolo was not consistent with a working diagnosis of drug intoxication. Doctors who suspect drug intoxication as the cause of abnormal mental status do not order brain CT scans.

 

However, doctors at the emergency department judged it worthwhile to order a brain CT scan as part of the evaluation of Mr. Micolo's evaluation. Physicians who believe that drug intoxication underlies an observed abnormal mental status would not order lumbar puncture (aka ‘spinal tap’) as part of the evaluation. Spinal tap is an invasive procedure with potential complications that include: pain,severe headache, infection of the central nervous system, and a potentially lethal condition known as herniation of the brainstem. Spinal tap is performed when there is suspicion of severe nervous system diseases or infections. Clinical laboratories do not analyze spinal fluid for he presence of drugs; further, the results of spinal fluid analysis cannot be used to confirm or reject the possibility that mental status changes are related to drugs. The fact the physicians elected to perform this invasive procedure on a patient with behavioral agitation speaks strongly to a belief at the time that Mr. Micolo had a severe physical illness - and that this severe physical illness either Erik Messamore, MD, PhD Consultant specialist in psychiatry and psychopharmacolgy emessamore@gmail.com originated within his brain or spinal cord, or was causing measurable abnormalities of his brain or spinal cord.

 

Third, he had a large number of abnormal lab findings during the course of his Emergecy Department evaluation. - Results of his spinal tap were, in fact, abnormal. Specifically, Mr. Micolo’s cerebrospinal fluid had abnormally high levels of glucose. There was also blood in his cerebrospinal fluid. Cerebrospinal fluid should be free from blood. However, the lab found red blood cells in each of the tubes collected from his spinal tap. - Lab tests reveal abnormally low potassium levels in Mr. Micolo’s blood. This is a condition known as hypokalemia. Mr. Micolo had hypokalemia at the time of his delirium. Most of the potassium of the body is stored inside the cells (not in the blood). When potassium levels in the blood fall, they are quickly restored by potassium from the rest of the cells in the body. By the time that blood potassium levels fall below normal limits, there has often been very substantial depletion of potassium levels throughout the body. Hypokalemia is a well-known cause of mental status alteration. Symptoms of hypokalemia include confusion and frank delirium. Hypokalemia can also cause psychosis. - Lab tests demonstrate that Mr. Micolo was in a state of metabolic acidosis on the night when he was delirious. Metabolic acidosis is the result of the kidney being unable to eliminate the acidic wastes of normal body metabolism. The accumulation of acidic waste lowers the pH of the fluids surrounding the brain. Cellular function, including the normal functioning of nerve cells, is critically dependent on precise regulation of pH levels. Low pH levels, which occur in metabolic acidosis has numerous effects on the body. The low pH causes a a reflexive increase in the rate respiration. The peripheral arteries dilate as the central veins constrict. Central nervous system activity becomes erratic, and mental status changes including anxiety, confusion, and delirium can occur.  - Lab results also provide direct, objective evidence that Michael Micolo was in renal failure at the time of his delirium. Creatinine, like metabolic acids, is a waste product of normal metabolism. Whereas metabolic acids can be converted to carbon dioxide and eliminated by the lungs, creatinine is solely dependent on the kidneys for elimination. Hence, the serum creatinine level is a widely used marker of kidney function. Mr. Micolo’s serum creatinine level of 2.1 is decidedly elevated and indicates seriously impaired kidney function. - Lab tests show that Mr. Micolo’s ability to regulate his blood glucose level was abnormal at the time of his delirium. His blood glucose level was 236 when he was admitted to the Emergency Department. This is an abnormally high level, and - unless he had been consuming a lot of sugar between his encounter with police and his initial set of blood tests in the emergency room - is very much unexpected in a young man with no history of diabetes. Reportedly, he had been exercising (walking in search of a lost puppy) rather than eating in the hours prior to his arrival at the Emergency Department. This being the case, one would expect his serum glucose level to be between 80 to 100. The elevation of blood glucose is suggests the presence of a medical illness. - Additionally, Mr. Micolo’s white blood cell count was extremely elevated when he arrived to the Emergency Department. He had 20,500 white cells per microliter of blood. (The upper limit of normal is 11,000). Elevations of this magnitude are seen in severe inflammatory states. Severe inflammatory states are also well-known to cause mental status changes, including delirium. To summarize his medical findings:

Descriptions of Michael Micolo’s behavior on 5/17/14 are strongly suggestive ofdelirium. The diagnosis of delirium is essentially confirmed by the presence of numerous signs of perturbed physiology. During this episode of delirium, Mr. Micolowas taken to a local Emergency Department where numerous physiologicalderangements, each entirely capable of impairing mental status, were detected.


Specifically, he was found to have:


1. Acute renal failure
2. Metabolic acidosis
3. Abnormally low blood potassium
4. Abnormally elevated blood glucose
5. Abnormally elevated white blood cell count
6. Abnormally elevated level of glucose in the cerebrospinal fluid
7. Blood in the cerebrospinal fluid


Furthermore, Mr. Micolo’s medical history suggests that is a high risk to develop delirium. Delirium is especially likely to occur when such physiological abnormalities occur in people with fragile or vulnerable brains. Mr. Micolo’s history is notable for a diagnosis of Attention Deficit Hyperactivity Disorder, i.e. a disease of the central nervous system thought to reflect abnormal brain functioning. Additionally, Mr. Micolo has suffered a closed head injury during his childhood. This is also expected to increase his vulnerability to delirium. In contrast, the hypothesis that his mental status alterations were drug induced, is not supported by medical evidence. It is noted that his drug screen was positive for marijuana. It is also noted that Mr. Micolo had used marijuana before. Therefore, his response to marijuana had been well-established and notable had not featured delirium. It is unlikely that exposure to the same drug had a different effect. There were no other intoxicants detected during medical evaluation. Finally, the discharge summary from his Emergency Department admission indicates that his sensorium cleared quickly and completely following the administration of intravenous fluids that contained bicarbonate. (Bicarbonate, a physiological alkaline substance, was added in order to treat his metabolic acidosis). It is very uncharacteristic of drug intoxication that mental status alterations can be reversed with fluids and bicarbonate (this is akin to being able to sober up by drinking a solution of baking soda). The fact that his mental status cleared from the administration of fluids and bicarbonate is strong evidence against drug intoxication as the cause of bad behavior. It is strong evidence for the case that he was suffering from delirium related to metabolic acidosis secondary to acute renal failure. His vulnerability to delirium is heightened by virtue of his pre-existing brain insults (head trauma and attention deficit hyperactivity disorder). Although the Emergency  Department evaluation did not reveal a cause for the abnormal glucose, elevated white blood cell count, potassium deficit, and cerebrospinal fluid abnormalities, these factors also contributed to increasing his delirium risk.
In my opinion, he was suffering from delirium secondary to the above-described medical causes at the time that he came to police attention on May 17, 2014.

 

Erik Messamore, MD PhD

 

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