OFFICE OF THE DISTRICT MEDICAL EXAMINER

DISTRICT 15 – STATE OF FLORIDA

PALM BEACH COUNTY
3126 GUN CLUB ROAD
WEST PALM BEACH, FLORIDA 33406-3005
(561) 688-4575
(561) 688-4592 FAX

NAME: Weaver, Damon Lazar Jr. CASE NUMBER: M21-00766

DATE OF DEATH: 05/01/2021 AGE: 23 SEX: M RACE: Black

DATE OF AUTOPSY: 05/02/2021 0915

AUTOPSY FINDINGS:

1. Male decedent with evidence of medical intervention

2. Mild coronary artery atherosclerosis
3. Congested purple lung parenchyma
4. Microscopic evidence of vaso-occlusive crisis
5. Medical records reviewed, summarized below
6. Toxicology/Chemistry/Laboratory:
a. In the antemortem/hospital blood, diphenhydramine (103 ng/mL), delta-9-THC
(5.3 ng/mL), THC-COOH (90.4 ng/mL), and naloxone are detected
b. The antemortem urine drug screen is negative (barbiturates and cannabinoids not
resulted secondary to insufficient sample volume)
c. Vitreous electrolyte studies are noncontributory (results in separate report)
d. Positive sickle cell screen on antemortem/hospital blood
e. Hemoglobinopathy evaluation not performed secondary to sample hemolysis

OPINION

CAUSE OF DEATH: Vaso-occlusive Crisis in the Background of a Reported History of Sickle

Cell Trait and Rhabdomyolysis Following Treatment for an Acute Psychotic Episode

MANNER OF DEATH: Natural

Anthony Vinson, D.O.

Associate Medical Examiner
Date Signed: 09/15/2021
NAME: Weaver, Damon Lazar Jr. CASE NUMBER: M21-00766

RATIONALE FOR OPINION

At 0630 hours, on 04/30/2021, the 23 year old male decedent, Mr. Damon Lazar Weaver,
was admitted to an area psychiatric center with a primary diagnosis of acute psychosis/brief
psychotic disorder. Vital signs from a history and physical note dated/timed 04/30/2021 1230 PM
revealed him normotensive, afebrile, with a normal respiratory rate and a slightly elevated heart
rate of 92 beats per minute. Skin turgor was noted to be within normal limits. Nursing notes
indicated that he slept through the first night with no complaints.

An incident report from the facility dated 05/01/2021 stated that around 0900 AM, the
decedent was having a psychotic episode. The nursing staff called for the assistance of a Unit
Supervisor who was able to de-escalate the situation verbally and Mr. Weaver voluntarily received
emergency treatment, intramuscular injections of 10 mg of Haldol and 50 mg of Benadryl. After
the injections, the notes indicate that the decedent continued to exhibit non-violent signs of
psychosis but his behavior was no longer deemed a threat to his safety or others. The incident
report documents another psychotic episode later the same day around 1300 hours. Again, the
nursing staff called for the assistance of the Unit Supervisor. Attempts at verbal de-escalation
ultimately failed and the decedent became combative. He was manually restrained. The available
records state he was given a second dose of intramuscular Haldol and Benadryl. Minutes later, he
received intramuscular injections of Geodon (10 mg), Benadryl (50 mg), and Ativan (2 mg).
Approximately 1 minute following the most recent injections he stopped moving, was breathing
heavily, and was unresponsive. His pupils were noted to be dilated and non-reactive. His systolic
blood pressure was recorded as 156 and his heart rate was 126. He was transferred to his bed and
Emergency medical services were summoned to the facility (dispatched at 1318 per Fire Rescue
Report).

Per the Fire Rescue report, emergency medical services arrived at 1322. They found a male
supine, unresponsive, and with labored breathing. He was transported to a local hospital for
medical clearance. Notable vitals from Fire Rescue during the transport are as follows: sinus
tachycardia with heart rates ranging from 90 to 139 beats per minute; variably normal to labored
respirations ranging from 14 to 24 breaths per minute; a blood glucose reading of 75 (mg/dL,
presumably); an axillary temperature reading of 36.7 Celsius (98.1 Fahrenheit); and blood pressure
readings ranging from 104 to 133 mmHg systolic and 63 to 109 mmHg diastolic. Shortly after his
arrival to the Emergency Room, he was found to be apneic and pulseless. Chest compressions were
initiated at 1345. He was intubated at 1350. A return of spontaneous circulation was achieved at
1422. He was to be transferred to another facility for a higher level of cardiac care. While awaiting
transfer, he was noted to be hypotensive, which was refractory to fluid boluses (at least 3 liters of
normal saline), and vasopressor support. Lab studies showed a deceased red blood cell count (3.05
MIL/UL), decreased hemoglobin (9.1 gm/dL) and hematocrit (28.8 %), profound electrolyte
abnormalities including an elevated potassium of 7.5 mmol/L (10.71 mmol/L when repeated),
elevated creatine kinase (3485 U/L) and troponin-I, and evidence of an acute kidney injury. A
urine drug screen was positive for cannabinoids. He became pulseless again at 1556 and
resuscitative efforts with ACLS protocols were initiated. Despite aggressive treatment, a return of
spontaneous circulation was not achieved and he was pronounced dead at 1644.

The decedent was brought to the Medical Examiner’s Office and a postmortem

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NAME: Weaver, Damon Lazar Jr. CASE NUMBER: M21-00766

examination was performed. The examination revealed no evidence of acute, life-threatening

traumatic injury or catastrophic natural event. There were no contusions in the cutaneous soft
tissues or the underlying musculature of the neck, chest, or back. There was a fair amount of scleral
and conjunctival hemorrhage as well as some shallow abrasions around the face, which may have
resulted from resuscitative efforts. Vitreous electrolyte studies were non-contributory. Toxicology
studies performed on the antemortem blood obtained from the hospital detected naloxone (which
was administered by clinicians), cannabinoids, and a non-toxic concentration of diphenhydramine
(Benadryl). The decedent was also documented as receiving Haldol, Geodon, and Ativan in the
psychiatric facility. I contacted the toxicology lab for clarification and was informed that the blood
sample did show a signal for both ziprasidone (Geodon) and lorazepam (Ativan) on the mass
spectrometry screen, but the concentrations were well below the screening cutoffs and therefore
reported as negative. The low to absent concentrations Geodon, Haldol, and Ativan may be the
result of some combination of metabolism and hemodilution secondary to the fluid boluses or
perhaps the injections missed the targeted tissue. Sections of several organs were processed for
microscopic examination. Interestingly, they all demonstrated some degree of vascular congestion,
often markedly, with sickled red blood cells in the lumens. In conversations with the family, it was
revealed that the decedent had a history of sickle cell trait, which was not documented in the
available medical records. In a phone call to the office of Mr. Weaver’s pediatrician, they said that
they had no documentation of sickle cell trait, but they also did not have his birth records, which
would have contained the newborn screening results. Blood samples were sent to another
laboratory for further testing and resulted in a positive sickle cell screen. Unfortunately, a
diagnostic hemoglobinopathy evaluation could not be performed on the remaining sample.

Upon his presentation to the hospital, Mr. Weaver’s laboratory results were consistent with
rhabdomyolysis. Rhabdomyolysis is a syndrome caused by muscular damage. The toxic
intracellular components leaked from damaged muscle can cause acute renal failure and profound
electrolyte abnormalities. There are many causes of rhabdomyolysis. Of particular significance to
this case, there are reports of rhabdomyolysis resulting from increased exertional activity, acute
psychotic episodes, and following prescription medication administration, particularly with agents
including antihistamines like Benadryl, and anti-psychotics like Geodon or Haldol. There is an
increased risk of rhabdomyolysis from exertional activity in those with sickle cell trait.

The findings in the post-mortem microscopic studies were consistent with a vaso-occlusive
(sickle cell) crisis. Sickle cell disease and its variants result from the inheritance of one or more
mutated forms of hemoglobin. Sickle cell disease is autosomal recessive, so when an individual
only inherits one copy of a mutated hemoglobin, they are carriers of the sickle cell trait (SCT).
Those with SCT are usually asymptomatic but that does not mean that it is a completely benign
condition. Red blood cell sickling can be induced in those with SCT when experiencing hypoxic
conditions, such as in periods of exertion. The resultant red blood cell sickling causes vascular
occlusion, which can lead to end organ damage such as renal failure and rhabdomyolysis, or can
impede gas exchange in the lungs.

During his final hours, Mr. Weaver was in the throes of an acute psychotic episode. The
facility staff attempted to pacify him verbally and through the use of chemical and physical
restraints. He became unresponsive shortly after being restrained and medicated, and underwent
cardiac arrest shortly after arrival to the hospital. There is evidence of rhabdomyolysis and vaso-

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NAME: Weaver, Damon Lazar Jr. CASE NUMBER: M21-00766

occlusive crisis, but it is not possible to pinpoint the exact cause of either or sequence in which
they occurred. Therefore, it is my opinion that the cause of death is Vaso-occlusive Crisis in the
Background of a Reported History of Sickle Cell Trait and Rhabdomyolysis Following Treatment
for an Acute Psychotic Episode. The manner of death is Natural.

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NAME: Weaver, Damon Lazar Jr. CASE NUMBER: M21-00766

EXTERNAL EXAMINATION
The body is that of a well-developed, well-nourished, 5 foot 8 inch, 188 pound man who
appears the reported age of 23 years. The body is refrigerated, well preserved, and not embalmed.

The head is normally formed. The atraumatic scalp has black hair. The eyelids are
moderately edematous. The brown irides and symmetric pupils are partially obscured by the
minimally cloudy corneas. The bilateral sclerae are edematous. The nasal bones are palpably
intact. The external auditory meatuses are free of blood. Facial hair consists of a mustache and
goatee. The lips are normally developed. The external labial mucosa and oral frenula are not
injured. The teeth are natural and in good repair.

The neck and chest are symmetrically developed. The soft, flat abdomen has a horizontal,
2.5 centimeter scar superior to the umbilicus. The symmetrically developed back has a horizontal,
3 centimeter, hypertrophic scar (keloid) on the inferior-lateral aspect of the left side. The external
genitalia are those of a fully developed adult, circumcised man. The anus is patent and
unremarkable. The testes are in the scrotum.

The symmetrically developed extremities have no congenital deformities or palpable

fractures. All digits of the hands and feet are present and are normally formed. Punctate scars, up
to 1.5 centimeters in greatest dimension, are on the dorsal surface of the right hand. The bilateral
fingernails are proximally cut to expose the nails beds. A 2 centimeter scar is on the left knee.

IDENTIFICATION

The decedent is visually identified by his mother. Members of the Palm Beach Sherriff’s
Office confirmed the identification via comparison to a photographic identification card. The
decedent is received with a hospital patient bracelet around the right wrist (inscribed with the
decedent’s name and date of birth).

CLOTHING AND PERSONAL EFFECTS

None.

EVIDENCE OF INJURY

Punctate, red brown abrasions, up to 0.3 centimeter, are on the bridge of the nose and the
superior left eyelid. A 1.5 centimeter, pink abrasion is inferior to the left eye. A minimal amount
of sub-scleral hemorrhage is over the right eye. Some mild conjunctival hemorrhage is on the left.
Shallow, superficial abrasions, lacerations on the interior mucosal surface of the lower lip have no
associated hemorrhage (vital reaction).

The lateral nail folds on the right hand are variably ulcerated (likely from onychophagia or
nail biting).

EVIDENCE OF MEDICAL INTERVENTION

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NAME: Weaver, Damon Lazar Jr. CASE NUMBER: M21-00766

An endotracheal tube in the mouth is secured with an anchor wrapped around the head.

A vascular access catheter is on the right side of the neck. Semicircular, patterned abrasions
are on the midline of the chest. A Foley catheter is in the urethra and the attached tubing and
reservoir contains optically clear, yellow urine. Defibrillator pads are on the right and left sides of
the chest.

Blood pressure cuffs are around the left and right arms. Vascular access catheters are on
the right antecubital fossa, and the dorsal surface of the right hand. Electrocardiogram leads are
spread across the chest, abdomen, and shoulders.

RADIOGRAPHS

Full body radiographs reveal medical interventions as described above, diffuse hazy
opacification of the bilateral lung fields, and no acute osseous injury.

INTERNAL EXAMINATION

BODY CAVITIES:

The ribs, sternum, and clavicles are intact. All body organs are in their normal anatomical
position. The right and left pleural cavities have no excess fluid or adhesions. The pericardial sac
has no excess fluid. The peritoneal cavity has no excess fluid or adhesions.

NECK:

A layered dissection of the anterior and posterior compartments of the neck reveals no
injuries or hemorrhage of the underlying soft tissue, musculature, large vessels, or vertebrae and
associated ligaments. The hyoid bone, thyroid cartilage, and larynx are intact.

CARDIOVASCULAR:

The 426 gram heart has smooth epicardial surfaces. The cardiac chambers do not contain
mural thrombi. The four, thin, pliable, cardiac valves have no deformities or vegetations. The
mural endocardium is thin, smooth, and translucent. The left and right ventricles are 1.2
centimeters and 0.5 centimeter thick, respectively. The interventricular septum is 1 centimeter
thick. The red-brown myocardium has no fibrosis, necrosis, or areas of accentuated erythema,
softening, or induration. The normally positioned ostia of the left main and right coronary arteries
are patent. The coronary arteries arise normally and course in a right dominant distribution.
Atherosclerotic plaque narrows the lumens of the left anterior descending, the left circumflex, and
the right coronary arteries up to, approximately, 20 to 30 percent. The thin, elastic aorta has a
normal course and caliber with intimal fatty streaks.

RESPIRATORY:

The upper airway, trachea, and mainstem bronchi are clear of obstructing masses. The

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NAME: Weaver, Damon Lazar Jr. CASE NUMBER: M21-00766

intact tracheal mucosa is mildly erythematous. The right and left lungs are 809 grams and 698
grams, respectively. The pleural surfaces are smooth. The markedly congested, edematous, purple
pulmonary parenchyma has no masses, granulomata, or discrete areas of consolidation. The
pulmonary arteries have no thromboemboli. The bronchomediastinal lymph nodes are not
enlarged.

HEPATOBILIARY:

The 1722 gram liver has a smooth, intact capsule covering a dark brown parenchyma with
a preserved lobular pattern and no focal lesions or vascular abnormalities. The gallbladder contains
yellow-green, mucoid bile and no calculi. The gallbladder’s mucosa is green and velvety.

GASTROINTESTINAL:

The tongue is uninjured. The esophagus is lined by an intact, gray-white, smooth mucosa
and is not dilated or stenotic, and has no varices. The stomach has a normal size and shape, and
the mucosa is free of ulcerations and is arranged with the usual folds. The stomach contains
approximately 150 milliliters of green-brown, viscous liquid. The small intestine is normal in
length, configuration, and diameter and has a smooth, shiny serosal surface. The mesentery has a
normal insertion. The large intestine has a smooth, shiny serosal surface and no palpable masses
or obstructions. The appendix is unremarkable.

The pink-tan pancreas has an intact lobular architecture and no parenchymal masses, cysts,
or hemorrhage.

RETICULOENDOTHELIAL SYSTEM:

The 110 gram spleen has an intact, smooth, gray capsule covering a homogenous, red-
purple parenchyma. The bone marrow of the ribs is dark red and soft. The lymph nodes of the
neck, chest, abdomen, and pelvis are unremarkable.

ENDOCRINE:

The adrenal glands and pituitary gland are unremarkable. The tan-brown thyroid gland has
a normal size and shape, and unremarkable parenchyma.

GENITOURINARY:

The right and left kidneys are 156 grams and 205 grams, respectively. The surfaces are red-
brown and smooth. The parenchyma has well-defined corticomedullary junctions. The ureters have
a normal course and caliber. The bladder contains 25 milliliters of clear, yellow urine and the tip
of the Foley catheter. The mucosa is tan, mildly trabeculated, and intact.

The prostate gland is unremarkable. The intra-scrotal testes have homogenous, yellow-
brown parenchymas and no masses or hemorrhage.

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NAME: Weaver, Damon Lazar Jr. CASE NUMBER: M21-00766

MUSCULOSKELETAL:

The musculoskeletal system is symmetrically developed. The muscles of the anterior neck,
chest wall, abdomen, and iliopsoas are symmetrical, firm, and red-brown. The ribs, pelvic bones,
and vertebral bodies of the cervical, thoracic, and lumbar spine are intact.

CENTRAL NERVOUS SYSTEM:

The reflected scalp has no hematomas. The skull is intact and has no fractures of the
calvarium or skull base. There is no epidural or subdural hemorrhage.

The brain is 1315 grams. The leptomeninges are thin and transparent. There is no
subarachnoid hemorrhage. The cerebral and cerebellar hemispheres are symmetrical. The
structures at the base of the brain, including cranial nerves and blood vessels, are intact. The thin-
walled arteries at the base of the brain have no berry aneurysms or other obvious abnormalities.
The substantia nigra is appropriately pigmented. The gray/white matter border is distinct. The deep
white matter has no nodules or masses. The symmetric basal ganglia and hippocampi have no
scarring or hemorrhage. The atlanto-occipital ligaments and proximal cervical spine, as viewed
from the foramen magnum, are intact.

TOXICOLOGY/CHEMISTRY

Blood, urine, and ocular fluid samples are sent to AXIS Laboratories for toxicology and
chemistry studies.

MICROSCOPY

H&E SLIDES: 9

KIDNEY – Markedly congested blood vessels forming lakes of sickled red blood cells.

PANCREAS – Partially autolyzed sections of pancreas and no inflammation, hemorrhage, or

malignancy. Sickled red blood cells are in vessel lumens.

THYROID – Colloid containing follicles of variable size lined by a single layer of cuboidal
occasionally flattened epithelium.

LIVER – Sickled red blood cells in the vascular lumens and variably congested sinusoids, macro
and micro vesicular steatosis, no fibrous expansion of the portal triads, no significant portal
inflammation.

BRAIN – Congested vasculature containing lakes of sickled red blood cells.

LUNG – Congested vasculature containing sickled red blood cells, collections of peri-vascular
and intra-alveolar pigmented macrophages, occasional peri-bronchial chronic inflammation.

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NAME: Weaver, Damon Lazar Jr. CASE NUMBER: M21-00766

HEART – Congested vasculature containing sickled red blood cells, medial hypertrophy of
arterioles.

SPLEEN - Markedly congested vasculature forming lakes of sickled red blood cells.

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