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‘A gnawing abdominal pain’: Inmate’s cause of death at Carroll County Detention Center leaves open key questions

A Carroll County Sheriff’s Office investigation into the Feb. 5 death of an inmate at the Carroll County Detention Center is looking at whether jail staff followed procedure, whether there were any criminal violations and whether there is anything the jail’s medical contractors could do in the future to prevent similar deaths.

Medical and legal experts say the analysis of such cases are all individual and nuanced, and highly dependent on the details.

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In the case of Nicholaus A. Cirillo, his death while in custody at the detention center appears to have been caused by an ulcer that can sometimes show symptoms only as it becomes more severe, a medical expert says.

Cirillo, 37, of Delaware, entered the detention center at about 11 a.m. Feb. 5 and complained of stomach pains. He was seen by nurse practitioners who gave him antacid medications but did not deem Cirillo to be so ill as to need to be taken to the hospital, according to Sheriff Jim DeWees.

“He had been checked twice by the medical staff there. We heavily rely on them, as we should; we’re not practitioners either,” DeWees said in a Feb. 10 interview with the Times. “If they say get them over to the hospital, we have protocols and procedures to get them over there.”

But at 10:57 p.m. Feb. 5, Cirillo was seen lying on the floor of his cell, and despite a response by correctional deputies and the Westminster Volunteer Fire Department, he was pronounced dead by 11:41 p.m.

After an autopsy, the Maryland Office of the Chief Medical Examiner ruled that Cirillo’s death had been caused by a perforated duodenal ulcer — that is, an ulcer of the small intestine that has eaten all the way through the intestine.

A perforation is typically the end result of a long-worsening condition in the intestine, according to Dr. Ma Somsouk, a professor of medicine in the division of gastroenterology at the University of California, San Francisco Medical School.

Bacterial infections and the use of nonsteroidal anti-inflammatory drugs — such as aspirin, ibuprofen or naproxen — can lead to an injury of the intestinal lining, he said.

“It goes from an erosion, which is a break in the lining, to something to something a little bit deeper, and then it becomes an ulcer,” Somsouk said, with the wall of the intestine exposed to and irritated by acids and bacteria.

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This process can take some time, and many patients have no symptoms early on.

“There are not really pain fibers on the surface lining of the stomach or the [small intestine],” Somsouk said. “But when it gets deeper, like a crater, and deeper as a deep ulcer, then that irritation goes all the way through the wall of the intestines, and that becomes sometimes a gnawing abdominal pain.”

While symptoms can come and go with an ulcer, they will typically become more severe and persistent leading up a perforation, according to Somsouk.

“Usually I would expect it to last for several weeks before it perforates,” he said. “It’s kind of like a process; it doesn’t spontaneously perforate.”

Definitive diagnosis is made through an endoscopy, Somsouk said, sending a camera into the intestine to take a look, but treatment and diagnosis typically begin simultaneously, with the administration of certain antacid medications.

“The most potent types are what we call proton pump inhibitors. Those are in the class of like Prilosec, Nexium, Prevacid,” he said. “Those medications work very well in terms of healing ulcers. If you’re on that, usually the ulcers will regress and you will get better.”

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A patient with symptoms of an ulcer who does not improve over a week with medication might then get an endoscopy, according to Somsouk.

That’s not a course of action that was available to the medical staff at the detention center, given the short time of Cirillo’s stay.

That the detention center was responsible for Cirillo’s health and welfare from the moment he entered, however, is not in question, according to a legal expert.

“Prisoners do not leave their rights at the door when they become incarcerated,” said Colin Starger, professor of law at the University of Baltimore. “Prisons and jails have an obligation to care for those under their supervision.”

Failure to provide adequate medical care to a prisoner can be considered cruel and unusual punishment under the Eighth Amendment to the U.S. Constitution, according to Starger, but only if the actions or lack of actions meet the standard of “deliberate indifference.”

“Ordinary medical malpractice ordinarily wouldn’t rise to the level of a constitutional violation. This is because ‘deliberate indifference’ is what is known as a ‘subjective standard,’ ” he said, where a jail official would have had subjective knowledge of a substantial risk of harm to the prisoner and ignored it. “In other words, it’s not about what a competent doctor ‘should have known,’ ” he said.

As an example, Starger said, a prisoner who was in prolonged or excessive pain, was unable to perform daily activities, or was complaining about a known dangerous condition could be a case that meets the “deliberate indifference” standard.

“The inquiry is very fact intensive,” he said. “It really depends on the specifics of what happened to the prisoner and what everybody knew.”

It’s not yet clear what everybody knew in Cirillo’s case.

DeWees has said that part of the investigation is looking into Cirillo’s possible medical records from institutions in Delaware to see if there was an ongoing problem that his people at the detention center were not told about.

And whether Cirillo was exhibiting the more severe symptoms of a perforated ulcer the evening of Feb. 5 is also not yet clear. DeWees has said that all the evidence he has, including surveillance video footage of Cirillo, show that he was walking and interacting with people almost up until the time he collapsed on the floor.

DeWees said in an email that he would be out of the office until next week and would not be able to comment for this story.

Cirillo’s aunt, his legal guardian when he was a child, spoke with him by phone at about 7 p.m. Feb. 5, and she said he complained that he was coughing or vomiting up blood.

That would be one of the symptoms to look for with regards to a perforated ulcer, according to Somsouk. Treatment in a hospital setting at that point, he said, is typically a CT scan to confirm the perforation, antibiotics to treat the infection and surgery to repair the hole.

“Anemia, a low blood count, or changes in vital signs. Fevers. Vomiting, black stools," he said. "Those are all signs pointing to bleeding or something severe.”

According to DeWees, however, Cirillo’s vital signs were fine when detention center medical staff checked him.

It’s also not clear when Cirillo’s ulcer perforated. According to Somsouk, while a perforation usually does not happen spontaneously, there is typically a marked difference in the pain level between a chronic, deep ulcer and one that has ruptured the intestinal wall.

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“That pain is really, it’s a very uncomfortable pain. Usually you’re kind of writhing,” he said. “By the time it perforates, the bacteria are all over the abdomen, kind of spreading all around, so people can’t really find a way to be comfortable.”

DeWees has said he will release the video footage of Cirillo after the completion of the investigation, which he has said will show Cirillo was in apparent good health up until the time he collapsed.

According to Somsouk, the signs of a perforation, under the circumstances, could have been easy to miss.

“If you only have less than 24 hours of attention," he said, “you’re not going to be able to do very much.”

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