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by Murder

  One way to do the victim in would be to replace the epinephrine with water. He would then succumb to the bee sting.

  Another way would be to tamper with the concentration of the epinephrine. Reducing it would probably not work since the net effect would be a partial treatment, which might be enough to allow the victim to reach the hospital. It would be better to increase the concentration.

  Epinephrine is basically speed. If given in large amounts, it can cause marked elevation of the blood pressure and deadly changes in cardiac rhythm that can kill almost instantly. The emergency bee sting kits are called Epipen Auto-Injectors and contain 0.3 cc of epinephrine at a 1:1000 dilution. This means that each cc of the medication contains 1 milligram (mg) of epinephrine. Thus, the delivery of 0.3 cc yields a dose of 0.3 mg.

  Increasing the dose by a factor of five or ten—a dose of 1.5 to 3 mg—could cause the desired result (cardiac arrhythmia and death), especially if given intravenously. In your scenario, giving either multiple injections (not practical) or tampering with the drug concentration in one of the injectors would do this. Substituting a more concentrated solution of epinephrine could work. The beauty of this approach is that no new drug is required, and the coroner might assume that the victim died from the standard dose of epinephrine, which can rarely happen, or from the allergic reaction itself. Of course, if the coroner tested the residue in the auto-injector, he would likely be able to determine that the concentration of the drug had been altered. But maybe not.

  If you want to add another drug, any speedlike product would do the trick, since the effect of the epinephrine and the other drug would be additive. Many of these are readily available. Cocaine (basically a speedball when mixed with an amphetamine such as epinephrine), crystal methamphetamine, and perhaps the rave drug Ecstasy, which is methylenedioxymethamphetamine, would work.

  The effect of this would be to raise the blood pressure and heart rate severely and rapidly, which could precipitate a heart attack. Also, these drugs can cause spasm of the coronary arteries, which could lead to a heart attack. Or the combination could cause a fatal change in heart rhythm. Cocaine and crystal meth are notorious

  for causing spasm of the coronary arteries and for precipitating deadly arrhythmias. In this case immediately after injection of the speedball the victim would feel warm and flushed, his heart would pound, and he might experience chest tightness or pressure, clutch his chest, and collapse. Or in the case of a sudden arrhythmia he might simply collapse with no warning symptoms at all.

  Can Insulin Be Used for Murder? How?

  Q: For my story, I need to know how easy it would be to kill someone with insulin. I know it can't be taken by mouth, but can it be given in an IV? Would the insulin overdose be detected in an autopsy? How much insulin would it take to kill an adult who is not diabetic?

  A: Insulin, which is produced in the pancreas by specialized cells called islet cells, is necessary for life. These islet cells constantly "read" the sugar level in the blood and secrete insulin as needed. The cells of the body require insulin in order to take in sugar from the bloodstream, metabolize it (break it down), and produce energy.

  Diabetics often have a deficiency of insulin or a faulty system for release of insulin from the pancreas. Untreated, this leads to elevated blood sugars, altered cellular sugar utilization, and a host of problems including diabetic coma and death.

  Excess insulin causes the rapid uptake of sugars by some cells and leaves none for the brain, thus leading to a hypoglycemic (low blood sugar) coma, brain damage, or death. Rare insulin-producing tumors can also cause profound hypoglycemia. And diabetics who give themselves too much insulin or don't eat enough after taking insulin can end up in the same situation.

  Since the brain, heart, and other organs need sugar for the energy to function, when the blood sugar level drops below 60 or so,

  symptoms of hunger, nausea, sleepiness, headache, and confusion appear. When the sugar falls further (30 to 50, say) all these symptoms worsen, followed by coma, brain damage, and ultimately death. Also, cardiac arrhythmias may appear and lead to death.

  Now to your questions.

  No, insulin cannot be taken orally. Digestive enzymes that break down food also digest insulin. Yes, insulin can be given by IV or added to an IV infusion of fluids. We do this from time to time to control very brittle (hard to control) diabetics who are in extreme circumstances.

  For your purposes an IV "push" dose of 50 to 100 units of insulin would do just about anyone in. A lesser amount probably would, too, but to be sure, 100 is a good number. It would work in less than a minute or two. It could also be given intramuscularly (injected into a muscle) or subcutaneously (injected beneath the skin, which is the method diabetics use to give themselves daily doses) and would have a slightly slower (fifteen to twenty minutes or less before the person lost consciousness) but still deadly effect.

  Yes, the coroner would be able to detect the excess insulin and the very low blood sugar at the postmortem exam. Of course, if the victim was a diabetic, he may write it off to an unfortunate incident. This happens to insulin-dependent diabetics all too often. Since your victim is not a diabetic, the presence of high insulin levels and low blood sugar would prompt a search for an insulin-secreting tumor of the pancreas, and when none was found, homicide would become the likely cause.

  Would Denying a Diabetic Insulin Cause Death or Just Illness?

  Q: For my story, I want to know whether a murder could be committed by substituting water for the insulin of a diabetic. What would happen to the victim, and how

  long would it take? Would the coroner be able to determine what had happened?

  A: Yes, a murder could be carried out in this fashion, but the victim would have to be an insulin-dependent diabetic. Let me explain.

  Diabetes is separated into two broad types. One is called adult-onset, non-insulin-dependent, or Type 2 diabetes. The pancreas in this situation produces insulin, though usually in reduced amounts. These people do not require insulin and are typically managed with diet and possibly medications. The drugs used in this circumstance either enhance the body's sensitivity to insulin or promote insulin production and release by the pancreas.

  The second type of diabetes is called juvenile-onset, insulin-dependent, or Type 1 diabetes. The pancreas in these people produces little if any insulin, and they require insulin to survive. Often when you hear on the news that a child is missing and needs to be found quickly because he or she needs important medicines, the problem is juvenile diabetes.

  In a Type 1 diabetic, tampering with or diluting the insulin or preventing the victim from getting it could lead to diabetic ketoacidosis, coma, and death. It may take a few hours or several days for the victim to get into trouble, depending on how much insulin is needed, how severe the diabetes is, and other factors.

  The symptoms of rising blood sugar and impending diabetic coma are fatigue, shortness of breath, nausea, thirst, excess urination (the high sugar in the blood is filtered through the kidneys and acts as a diuretic, causing a sudden increase in urine volume and leading to dehydration), lethargy, somnolence, confusion, and finally coma and death.

  At autopsy the M.E. would find elevated blood sugar and acidosis, which would lead him to conclude that the victim died from diabetic ketoacidosis. He would not be able to determine why the victim didn't take his insulin or why he took an inadequate amount. That said, the M.E. would not only examine the victim but also all the evidence collected at the scene that might bear on the cause and manner of death. He could test the insulin bottle found in the victim's house and discover that it had been diluted, which might lead him to consider homicide as the cause of death.

  Is There a Lethal Substance That When Given to a Patient Might Appear to Be a Hospital Blunder Rather than a Homicide?

  Q: have a killer (fictional, of course) who is attempting to murder a hospitalized patient by putting some material through the IV while he sleeps. What readily available substance could h
e use to make the hit look like a hospital blunder rather than a homicide?

  A: In the hospital setting, many drugs are available that would surely fit your story requirements.

  Any of the muscular paralytic agents would work. This class of drugs paralyzes all the muscles, including those used for respiration. The victim would stop breathing and die. Since these drugs work on all the muscles, he would not be able to move or speak or cry for help. Anectine and Pavulon are examples. Anectine (succinyl-choline chloride) comes in multidose vials of 10 cc that contain 20 milligrams (mg) per cc of the drug. Give the entire 200 mg through the IV and paralysis will occur in a matter of seconds. Pavulon (pancuronium bromide) comes in 10 cc vials with 1 mg per cc of the drug. Again, give the entire vial intravenously.

  Almost any narcotic or barbiturate (barbie) would also work. In large doses they depress and can even stop respiration, and they are available in most hospital wards and/or pharmacies.

  Common narcotics include Morphine (MS, or morphine sulfate), Demerol (meperidine hydrochloride), and Dilaudid (hydro-morphone hydrochloride). Once again, overkill is the operative word, so very large doses should be given intravenously to assure the desired effect. For MS give 100 mg; Demerol, 250 mg; and Dilaudid, 20 mg.

  The two most common injectable barbies are pentobarbital (trade name Nembutal) and sodium phenobarbital. Giving 2 to 5 grams of pentobarbital or 500 to 1000 milligrams (1/2 to 1 gram) of phenobarbital would do anyone in.

  The problem with all of these drugs is that they are traceable. And since they work by stopping respiration, it would take a couple of minutes for the victim to die, which allows time for the nurse to discover the person is in trouble and begin lifesaving measures. Thus, the patient would have to be on the ward and not in the ICU or Coronary Care Unit where they have cardiac and respiratory monitors that sound a warning if respiration drops. On the wards these devices are used less often, and the nurses aren't always in eye contact with the patients, so the victim could die before anyone knew about it.

  Another option would be injecting potassium chloride (KC1) intravenously. This is the truly lethal part of lethal injection executions. It stops the heart immediately. A dose of 50 to 100 milli-equilivents (meq) pushed rapidly intravenously will kill anyone. Milliequivalents is a chemistry term that would be very difficult to explain, and you don't really need to know this to craft a credible scene. It comes in vials that contain 40 meq per cc. It is easily available in a hospital, and right or wrong is often left lying around. It is commonly given to patients with low potassium levels as part of their IV fluid infusion—at slower rates than an IV push, of course. This would be traceable in that a high potassium level in the blood would be found at autopsy. That said, it could still be written off as a medical error, and the nurse could get blamed.

  A better bet would be to use a drug that the victim is already taking and simply give him a large dose. This could easily be deemed a medical error. For example, if the victim had heart disease and was taking one of the antiarrhythmic drugs (commonly used medications that treat abnormal cardiac rhythms), giving a large dose could kill him, and finding a high level in the victim's blood at autopsy might be interpreted as physician or nurse error. Examples of these drugs would be quinidine and procainamide. Give 1,000 mg of either by rapid IV injection, and the victim's heart would come to a standstill in a minute or two.

  Another possibility would be digitalis, a common cardiac medication. Digitalis is manufactured under several trade names. The most common is Digoxin, and the typical daily oral dose is 0.25 mg. Giving 2 mg intravenously would kill almost anyone in a few minutes by causing a deadly change in cardiac rhythm. Again, this could appear to be a nursing error.

  What Drugs or Medicines Will Become Deadly When Combined with an MAO Inhibitor?

  Q: I have a female character who recently had a face-lift. She does fine through the surgery and is released with antiinflammatory and pain medications. Two days later she dies because of a severe reaction to her medications. An autopsy discovers that someone substituted one of her medications for something dangerous. I was thinking of MAOI. Will this work? Can you give me the names of the medications prescribed and the substitute that would kill her?

  A: The answer is very complex, but I'll try to keep it as simple as possible.

  The monoamine oxidase inhibitors (MAOIs) are a strange group of drugs and very treacherous. So much so that most physicians avoid using them, and many of the older MAOIs are off the market. However, some still exist and are used in the treatment of depression.

  Nardil (phenelzine sulfate) is still around and is a very potent MAO inhibitor. It comes as a shiny orange pill with "P-D 270" stamped on it in brown lettering. The tablet contains 15 mg of the active compound.

  The physiology of MAO inhibitor action is very complex, and I won't bore you with the details. The important thing is that if these drugs are given with certain other drugs and foods, severe and potentially lethal reactions can occur.

  The most dangerous drugs to combine with the MAOIs are the sympathomimetics. These are the adrenaline or speedlike drugs. Cocaine, epinephrine (often used with local anesthetics to lessen bleeding; an example is lidocaine with epinephrine that dentists use frequently), pseudoephedrine (found in Sudafed and Actifed), amphetamines (found in nearly every diet pill), and certain serotonergic drugs can cause serious reactions. Most decongestants, asthma inhalers, cold medicines, and diet pills contain these or similar compounds that can lead to deadly interactions.

  Also, foods that contain high concentrations of tyramine, L-tryptophan, or dopamine can cause dangerous reactions. These include aged cheeses, dry sausages (pepperoni, hard salami), pickled herring, fava beans, beer, wine, liver, yeast extract, and even caffeine and chocolate.

  Now you can see why the MAOIs have fallen into disfavor. There are simply too many substances that can interact with them and cause lethal complications.

  The most deadly reactions include the following:

  Hypertensive crisis: The blood pressure (BP) shoots up rapidly to very high levels—250 to 300 over 100 to 130 wouldn't be unusual. This can cause confusion, disorientation, headache, blurred vision, seizures, loss of consciousness. It may lead to a stroke, a bleed into the brain, or a heart attack. Treatment is the administration of 5 mg of phentolamine intravenously to lower the BP rapidly.

  Hyperpyrexia: The acute and severe elevation of body temperature. Temperatures of 106 to 108 and higher may occur. Any time

  the body temperature rises above 106, brain cells begin dying in fairly short order and death follows. Treatment is an ice water bath.

  In your scenario it would be easy to substitute two of the victim's medications with Nardil and any of the currently available diet pills such as Meridia (silbutramine hydrochloride monohy-drate, which is supplied in capsules: blue/yellow is 5 mg; blue/ white is 10 mg; yellow/white is 15 mg) or Fastin (phentermine hydrochloride, which is supplied in 15 and 30 mg capsules). For the most potent lethal effect, begin the Nardil several days (two to eight or more) before giving the diet pill. A hypertensive crisis could ensue rapidly, and the victim would suffer a stroke or cardiac arrest. This could occur within twenty to thirty minutes or up to several hours after the medication was taken.

  The victim would develop a severe headache, blurred vision, dizziness, nausea, shortness of breath, confusion and disorientation, perhaps chest pain, perhaps a nosebleed from the high BP, and then collapse and die. These events could occur over several minutes to a few hours, whichever works for you.

  As I said, this is a complex topic but an interesting question.

  Follow-up Question and Answer

  How Does a Physician Distinguish Between a Drug-Induced Fever and One from an Infectious Process?

  Q: Could the elevated temperature be misdiagnosed as an infection at first? What would an autopsy pick up in such a situation?

  A: Yes, the elevated temperature could lead the M.D. down the wrong road and probably would. An adage in
medicine is that "common things occur commonly." A person with very high fever and lethargy or coma or seizures or other neurologic symptoms

  would be assumed to have an infection first—particularly an infection of the brain such as meningitis or a brain abscess. Only after these were ruled out would other things be considered. And in the real world a drug interaction with MAOIs in a patient who wasn't taking those medications would not likely even come to mind. Therefore, it would be found only if the M.D. taking care of the victim obtained a drug screen and it appeared there.

  The tests to rule out the infections mentioned above could include blood cultures, CT or MRI brain scans, a spinal tap to examine the cerebrospinal fluid for infectious critters and white blood cells, and an EEG (brain wave test), for starters.

  In your scenario the victim could collapse or suffer a seizure and be taken to the ER, where her temperature would be found to be 106 and the workup for a brain infection would then ensue. Her blood pressure would likely be very elevated, which can also happen in brain infections if the brain swells and the intracranial pressure (pressure inside the skull) rises. The victim could die in a few hours, which would automatically make it a coroner's case. Anyone who dies within twenty-four hours of hospital admission must at some level be reviewed by the coroner.

  The M.D. wouldn't know if the cause of death was indeed an infection or not. The coroner would perform a postmortem exam, find no signs of infection, and would then await the toxicology and other tests before determining the true cause of death. This may take a few days.

  Can a Patient Be Killed by the Rapid Injection of Potassium Intravenously?

  Q: Does this sound like a credible way for my villain to kill a hospitalized patient? An insulin syringe filled with potassium chloride (40 meq per cc) is injected quickly into an IV line just above the point where the IV's