Even as they draped a large American flag over the bodies–the blackened wreckage of the Sheriff’s Ford Interceptor still atop the dumpster where it had come to rest–the other deputies must have wondered why.
Why was Jason Garner going so fast? Why did his vehicle leave Crows Landing Road? Why didn’t he steer it back onto the blacktop? Why did this happen?
As they followed the flatbed carrying the wreck with the bodies still inside to the Coroner’s facility on Oakdale Road did any of them wonder if the Explorers or Interceptors in which they spent much of their workday represented any danger to them?
After all, carbon monoxide detectors had been ordered by Sheriff’s administration for use in the patrol cars, and there had been scuttlebutt and personal experiences that exhaust fumes might be a problem.
Publicly, and without qualification, the CHP has said carbon monoxide, a part of exhaust gases, was not a factor in this May 13, 2017 crash…not a reason why Deputy Garner accelerated to almost 90 mph, weaved back and forth and finally steered straight…throttle to the floor…into a wrecking yard just south of the junction of Crows Landing and South Seventh Street.
But, within a month lab tests showed carbon monoxide poisoning, according to Albert Donnay, MS, MHS, a consulting toxicologist based in Maryland who specializes in carbon monoxide poisoning.
The percentage of hemoglobin in blood carrying carbon monoxide instead of oxygen was 19%, according to the toxicology report.
The average level for a non-smoker like Deputy Garner is less than 1%, the World Health Organization recommends a 2.5% level or less at the end of a workday where carbon monoxide in the workplace is unavoidable.
The Center for Disease Control, in a page updated in September of 2017, says one of the signs of carbon monoxide poisoning is “altered mental status” and in a highlighted box says:
“An elevated COHb level of 2% for non-smokers (which Deputy Garner was) and (over) 9% for smokers strongly supports a diagnosis of CO poisoning.”
More importantly, the WHO says driving ability, among other things, is impaired at as low as 5.1%. His was almost four times that amount and, in fact, was probably higher because of a sampling error we will discuss later.
Deputy Garner’s level was 19%. CSO Johnson has a higher test result but, she did breathe after the crash, as evidenced by soot in her airway.
Back to the Coroner’s facility: Some of those who worried about exhaust leaks in their patrol cars conveyed that worry to Dr. Eugene Carpenter Jr. before he did the autopsy two days later. He told us so in a telephone interview.
We told him that we had read many autopsy reports and that we were struck by how carefully he examined the airways and lungs of the two victims. With a post-crash fire you would expect to see evidence that gases were inhaled, as well as getting a confirmatory lab result.
Here’s what he reported about Deputy Garner: “The airway is clear and free of signs of inflammation. Froth is not detected. Soot is not detected. The effect of flames on the airway mucosa is nonexistent. There is no redness of the airway mucosa and no edema.”
Later in the report he added; “Death is very rapid from a high speed collision with fixed objects. The mechanism of death would be from massive concussive forces to the head, neck and chest, and in addition, a very heavy weight coming to occupy the anterior (front) surface of the chest wall.”
And, he said: “Another main cause of death is massive force to the chest in the area of the heart, which can cause heart and respiratory action to cease immediately.”
In a telephone interview we told Dr. Carpenter we read that report to say Jason did not take a breath. He confirmed that was an accurate reading. If he did not take a breath, he could not have inhaled carbon monoxide from the post-crash fire.
If carbon monoxide somehow entered the airway from the post-crash fire, how could he have made the observation that “The effect of flames on the airway mucosa is nonexistent”, as he did in his report?
We also discussed the fact that his report noted an enlarged left ventricle of the heart which he said “could not be ruled out” as a cause. However, in his experience, the erratic driving, including swerving and accelerating are inconsistent with death cause by an arrhythmia from an enlarged ventricle.
In contrast, soot was found in the airway of Raschel Johnson. He said “a few breaths” were taken by CSO Johnson even though she was unconscious from the impact, and died within seconds.
For both he asked for blood testing for carbon monoxide. However he asked for carbon dioxide testing only for Deputy Garner. Carbon dioxide is a component, along with carbon monoxide, of exhaust gases.
So he took blood samples from each and sent them off to the lab…in what appears to have been the wrong type of vial.
The vials are color coded. The color of the top of each vial tells what preservatives or chemicals are already in the vial. A review of the protocols for various labs, including the ubiquitous Quest Diagnostics, call for samples which are going to be tested for carbon monoxide to be in either lavender or green topped tubes.
At least one study shows that carbon monoxide samples degrade in gray topped tubes, which is what Central Valley Toxicology noted the samples were in when received on May 17. We do not know when the samples were actually tested. The lab director signs the reports on May 24, 13 days after the crash.
This means that the amount shown is probably less than the amount actually in the blood., according to Donnay.
If that is correct, Deputy Garner’s carbon monoxide level was greater than the 19% reported and CSO Johnson’s level of 27% was higher than reported. Her level was 40% higher than his because she did not die on impact as he did and so inhaled additional carbon monoxide after the crash from the fire as evidenced by soot found in her airway.
So, what do those blood levels mean? Here a second problem arises.
On the toxicology reports, dated, May 24, 2017 Central Valley Toxicology printed some “standard” levels for the effects of various levels.
They said the “effective level” was 1-5% for a smoker and 8-10% for a smoker; the “potentially toxic” level was 24-35% and the “lethal” dose was 50-60%.
Questioned as to the source of these standards lab director Bill Posey cited the International Association of Forensic Toxicologist (IAFT) and a textbook by Randall Basel Ph.D. Mr. Posey did say these were meant only to be guidelines. It does not say that where the standards are set out in the toxicology report.
We asked Toxicologist Donnay about these standards. He said he checked with the IAFT retracted those standards years ago and no longer publishes any reference ranges for carbon monoxide in blood because there is so much variation among individuals.
Donnay says: “There are no magic numbers”. One person shows no symptoms at 20% while another person may die.
The World Health Organization suggests that 2.5% should not be exceeded for non-smokers even in a workplace where carbon monoxide exposure cannot be avoided.
The WHO says: ”Psychomotor effects such as reduced coordination, tracking and driving ability and impaired vigilance and detection of small environmental changes have been revealed in double bind studies at (carbon monoxide) levels of 5.1-8.2%”.
One problem is that it is virtually impossible to test for toxicity minimums because it cannot be predicted who might die from a relatively low dose.
With Deputy Garner’s level of 19% or more, Donnay says it would be unusual if his cognitive functions, including driving ability, were not affected.
As with the variations of the effect of a given dose, there are variations in the symptoms, subject to subject. For some, the first symptom is nausea; for others it is fatigue. But, more relevant first symptoms include confusion, disorientation and even hallucinations.
We described the driving pattern to Donnay and it is his opinion that the documented exposure could explain the otherwise unexplainable swerving, speeding and “freezing up” in the last few seconds.
It is hard to tell from the documentation when Dr. Carpenter’s studies were completed. He signs off on CSO Johnson’s report on 6-5-17, the same date he initials the toxicology report to document he has reviewed it. He does not sign off on Deputy Garner’s report about until three months later, three months after initialing the toxicology report, yet mentions nothing about the toxicology findings in his report.
The disconnect appears to be the failure to flag or understand the possibility that Deputy Garner suffered carbon monoxide poisoning before the post-crash fire. If he didn’t breathe after impact, carbon monoxide did not enter his bloodstream.
If the Central Valley Toxicology lab report standards were taken at face value, Deputy Garner’s carbon monoxide level had not reached toxic levels.
With the concern of other deputies about the safety of the vehicles they were driving, and with Dr. Carpenter aware of those worries, it might be expected that if he thought carbon monoxide was not a factor he would have said so in his report…again not signed off until three months later.
One question that has arisen is whether or not there was sufficient time that morning for Deputy Garner to have received sufficient exposure. Donnay says that would depend on the origin of the leak, how much of a “load” of carbon monoxide found its way into the passenger compartment of the idling patrol vehicle and how much was taken up while accelerating at high speed which is the worst case scenario that Donnay has identified from his own testing of Ford Explorers.
Asked in an email why the redacted CHP report does not contain the words “carbon monoxide”, Sgt. Robert Shaw of the Multi-Disciplinary Accident team said they did not consider it because they were not pointed in that direction by the Coroner’s office. “We are not doctors”, he explained.
So, we delivered a letter to the Coroner’s Sergeant who wrote the narrative report asking that the office review certain facts, like the use of the wrong vial for testing and Mr. Posey’s email statement that the reported standards were only guidelines. We asked that they consider doing an addendum to the report which would point the CHP in the direction of carbon monoxide as a possible cause. When we followed up with a telephone call, we were told everything had to go through the county counsel.
So, a week ago we asked for a response, for publication, to our request to put carbon monoxide poisoning in the mix so the CHP could reconsider. There has been no response.
The toxicology report says there were no drugs or alcohol in Deputy Garner’s blood and mechanical defects were eliminated, according to the CHP. So we look to Deputy Garner’s actions or inactions for a cause.
“Nobody in their right mind would drive a vehicle in that manner…” Officer Olsen told the Bee.
That sounds right.
————————————————————–
(Notes: We did not intend to minimize the personal loss to the families or the community. This exercise was aimed at determining whether or not the public got the type of investigation expected when two valuable public employees are lost. Raschel Johnson is mentioned minimally because this series concentrates on the cause of the crash, rather than the loss of the lives. Modifications have been made to the fleet of sheriff’s vehicles since this incident designed to eliminate or minimize exposure to exhaust gases.)
A Little Long Form Journalism 