Essam Atta autopsy – Conflicts in the eyewitness doctor report

I rarely get to blog about medicine here but I just want to highlight a few conflicts between the official reports on the cause of death for the alleged torture victim, Esaam Atta, and the account of an eyewitness to the autopsy, Dr. Ahmed Seyam, who is affiliated to a group named “Tahrir Doctors”.

Dr. Seyam describes the contents of the stomach on autopsy examination as containing “white food like material” in addition to a ‘foreign body’. On examining the stomach wall, he also describes a dark circular area of about 10 cm in circumference which he diagnosis as a gastric ulcer and which we hope was biopsied. He also mentions that this ulcer does not perforate the stomach wall.

تم تفريغ محتويات المعدة بفتحها و تم أخذ عينة من المحتويات التى بدت كطعام أبيض ممضوغ و تبين إحتواء المعدة على “جسم غريب” . بعد فحص جدار المعدة الداخلي تبين وجود منطقة متلونة بلون أغمق مما حولها بشكل دائري بقطر حوالي عشرة سنتيمترات و هو ما يعنى وجود تقرح بالمعدة قبل الوفاة ، و هذه المنطقة المتقرحة لم تكن مثقوبة الى السطح الخارجى لجدار المعدة

He later describes the foreign body as covered in “yellow surgical latex gloves” which also contains red pills. I assume he’s suggesting the red Morphine Sulfate pills which are available in Egypt as pain medication.

عبارة عن جسم اسطواني غير منتظم بطول سبعة سنتيمترات و قطر سنتيمترين تقريباً ، عبارة عن محتويات مغلفة بأصابع قفازات جراحية “yellow surgical latex gloves” مدخلة أحدها فى الآخر أكثر من مرة و انفلت منها داخل المعدة قبل التشريح أحد طبقات التغليف من المادة المذكورة تاركة احدى نواحى الجسم الغريب أقرب الى الشفافية ظاهراً منها جسم من مادة بنية صلبة على شكل عمود ذو مقطع مربع بأبعاد نصف سنتيمتر عرضاً و طولاً و أربعة سنتيمترات ارتفاعاً تقريباً و خلفه مساحة تساوي تقريباً ضعف المساحة الموصوفة و لكنها معتمة لا تظهر ما بداخلها ، و أسفل منه على الناحية الشفافة تظهر حبوب كحبوب الأدوية ذات لون خارجي أحمر ذاب ليظهر داخلها لون أبيض و خرج ذلك اللون الأحمر الذائب من ثقب بمادة الغلاف المذكورة “اطبع القفاز” ليصبغ خارج الإصبع بنفس اللون الأحمر.

* تم أخذ الجسم كما هو دون فتحة كعينة للتحليل ، و شهدت استخراجه من المعدة بعد فتحها مباشرة بعينى مبتلاً بالسائل اللأبيض الغليظ الذى يبدو كطعام مهضوم المذكور سابقاً

The report from the Ministry of Interior (MOI) explains that Essam Atta suffered from a severe sickness followed by a loss of consciousness. He was first examined by the prison physician and was moved to the prison hospital. After his condition deteriorated further he was referred to the Toxicology department at Qasr ElAini University Hospital where he was pronounced dead due to hematemesis (vomiting of blood) and circulatory failure as a result of an, hitherto, unexplained drug toxicity.

وعلي الجانب الآخر، استنكرت وزارة الداخلية تفاصيل هذه الرواية، مؤكدة أن عصام علي عطا شعر عقب زيارة والدته وخطيبته بحالة إعياء شديدة وفقدان للوعي وإفرازات رغوية من الفم والأنف، وبتوقيع الكشف الطبي عليه بمعرفة طبيب السجن تبين إصابته باشتباه تسمم دوائي حاد تم نقله علي إثرها إلى مستشفى السجن، ومع استمرار حالة الإعياء التي أصابته تم تحويله إلى مستشفى المنيل الجامعي، قسم السموم، والمستشفى تابعة لمستشفى قصر العيني.

وأفاد تقرير المستشفى أن الوفاة ترجع إلى وجود قئ دموي حاد أدى إلى هبوط في الدورة الدموية وتوقف في عضلة القلب نتيجة تسمم غير معروف

I have several problems with Dr. Seyam’s report. He describes a 10 cm gastric ulcer which seems to be in line with the University Hospital report for the cause of death (vomiting of blood). However, Dr. Seyam’s description of the stomach contents “white ingested food like material” seems to contradict that any form of bleeding had ever taken place. In such cases there would be evidence of blood discoloration of gastric contents (reddish) or more commonly in its altered form which is tarry black in color. In fact the presence of food remnants, according to his account, seems to also contradict that any vomiting took place in the first place and suggests that a stomach wash (where stomach contents are emptied medically) was not performed.

Let me be clear about a few other facts: Ingestion of Cannabis or Hashish (resin form) does not cause a gastric ulcer. In fact marijuana (the unprocessed “weed” form which is referred to in Egypt as “bango”) is used to treat gastric ulcer. Medical marijuana (bango) is prescribed to ease the ulcer pain and is ingested as well as smoked (less preferable).

Internal concealment of very large amounts of drugs of abuse is known as “body packing” may lead to gut obstruction and subsequent perforation. This however, has readily been discounted by the young physician who asserts there was no perforation of the stomach wall.

If it’s not the marijuana or the body packing then we’re left with the red pills. Since they are “pills” we can assume they are safe for ingestion (not corrosive) and will not lead to ulcer formation. Even if we assume there are other opioids (heroin) in varying quantities none are known to be ulcer producing. UPDATE: One possible exception is crack cocaine which is the rock crystal form that has not been neutralized by an acid to make the hydrochloride powdered salt. Crack cocaine has been associated with giant ulcers (more than 2 to 3 cm) and ulcer perforation. However, crack cocaine has almost no effect when ingested, it is heated and its vapors are smoked. Cocaine (even in its powder form) is only poorly absorbed by the gut. Regular amphetamine use is another risk factor for giant ulcers but ingestion and “body stuffing” is mainly associated with systemic toxicity such as heart problems, not blood vomiting. Either way, Dr. Seyam’s report does not indicate bleeding, vomiting or perforation.

Opioids (morphine, opium, heroin) as well as cocaine can cause vomiting in general. Theoretically speaking severe vomiting can lead to a superficial mucosal tear in the stomach wall and lead to vomiting of blood (Mallory Weiss Syndrome). However, Mallory Weiss is caused by alcohol binge drinking and certainly doesn’t produce a 10 cm dark circular area as he described and only rarely causes death. And even if we extend our sense of disbelief yet again we are left with no evidence for altered blood in the stomach contents as described by the eyewitness himself.

Obviously we should all wait for the final report. It’s not wise to reach any conclusions whilst information is sparse. But I thought I would share some of my initial thoughts regarding the eyewitness report. Even by looking at the photo of the deceased (see reference below) you can clearly see evidence for bleeding as confirmed in both the University Hospital and MOI reports.

I don’t think Dr. Seyam is in a position to accuse the prison doctor of malpractice which he does here:

اتهم من تعامل مع حالة المريض قبل الوفاة طبياً بالتقصير المهني لعدم تشخيص وجود الجسم الغريب مع النزيف بالمعدة ، و كذا عدم اجراء غسيل معوي.

If the deceased was indeed unconscious then a stomach wash SHOULD NOT be performed, contrary to Dr. Seyam’s accusation.Likewise I’m not in a position to discredit either him or the forensic team that undertook the examination. Rather if the deceased was indeed a victim of torture, Dr. Seyam should not discount the possibility that the evidence including “white undigested food like substance” could have been planted inside the stomach by the perpetrator.

References

1. Dr. Seyam’s eyewitness report. http://ahmadsyiam.blogspot.com/2011/10/blog-post_29.html

2. Essam Atta Photo