TPM DR Reader FP ...

As a physician, I agree that a bullet to the neck looks a lot different than a skull fracture. But there are several caveats. When a trauma victim comes into the ER, you tend to believe the story you're told as long as it's generally consistent with what you're seeing. In Bhutto's case, I assume someone said something along the lines of, "There was gunfire and then a bomb." That's broadly believable. If there are inconsistencies in the story, you usually don't start asking questions until the patient has been stabilized. (You see this a lot in child abuse cases. The story will be something like, "He fell off his bike." Your first task is to make sure the kid's okay. There's no reason to question the story until the radiologist calls and says, "There's no way this fracture was caused by a fall.") In Bhutto's case, she died less than an hour after coming in. Once the patient is dead, you usually stop asking questions, and the case goes to the medical examiner and possibly the police. The story I heard is that her husband didn't want an autopsy, so the body was released without one. That probably wouldn't happen here, but we're talking about Pakistan, and I'd guess that the authorities would do whatever her husband asked.

The other big thing to think about is where the information is coming from. I don't know what the ethics rules are in Pakistan, but in the US, you can't give out ANY information about a patient without some sort of consent. As far as I can tell, none of the information here is coming from Bhutto's doctors. Doctors can't just call a press conference to talk about their patients, even if there are news stories out there that are wildly inaccurate.

TPM DR Reader DS ...

Cardiac arrest from a head injury would require sufficient internal bleeding to cause pressure on the brainstem. I have a hard time accepting that a self-inflicted, "if only she had stayed in the vehicle" kind of injury would generate that level of intracranial bleeding, certainly that quickly. If they attribute the head injury to concussive force from the blast, it is implausible to me that she would have lacked shrapnel injury; either the armored vehicle shielded her or it didn't, but it wouldn't do so selectively. To my ears, the whole thing sounds like the Pakistani government deflecting blame for the attack by saying her death was her own damn fault. I find the lack of a post-mortem troubling, and will have a hard time believing any kind of official pronouncements on the subject.

TPM DR Reader DS (another DS) ...

I am not a forensic pathologist, and so my opinions should be taken with something of a grain of salt. However, as a pediatrician, I see a fair amount of head injuries, both acutely and in follow-up. I find the explanations coming from Pakistan regarding the mechanism of Bhutto's demise to be unconvincing, to say the least. If they are positing that Ms. Bhutto died from an essentially self-inflicted injury while ducking, I find that contention absurd. It is implausible in the extreme that she would have generated sufficient velocity in ducking that short distance to sustain a skull fracture, much less a fatal head injury that would have prevented emergent resuscitation. And yes, any reasonably competent physician would be able to distinguish between a gunshot wound, a shrapnel injury and a skull fracture, open or closed. Further, if no post-mortem was done, it is essentially impossible for them to attribute the cause of death to a head injury, unless it was an open head injury. Traumatic brain injury as a cause of death cannot be effectively diagnosed by visual inspection alone. If an open head injury is supposedly the cause of death, shrapnel is a much more likely cause of the injury than ducking. I find their explanation patently preposterous.

Having read through a number of educated and/or expert responses, and taken them in through the prism of my medical ignorance, a few points jump out at me. The first is that we haven't heard anything from a doctor who was actually there, which is key. We've heard things from government officials who at various points had strong interests in getting some information out quickly or exculpating security or inculpating different possible assailants. Second, in the chaos of a very high-pressure and grave medical emergency there are probably all sorts of misunderstandings and misdiagnoses that were possible.

The key to me is that it's very hard to see how the knowledge of the cause of death improved after she died if there was no post-mortem examination of the body. Indeed, given the chaos of the situation and the lack of a post-mortem, it's difficult to see how how a closed head injury as the cause of death was confirmed and, even odder to me, how the authorities could have isolated such a precise explanation of the injury. You have gunshots, a major explosion and then lots of chaos afterwards, and without a post-mortem examination you're able to determine that the cause of death was a head injury sustained when the vehicle lurched down from the gunfire and inadvertently struck her head on the sunroof?

Let me be clear: I'm not alleging a conspiracy here or that she didn't die in one fashion or another because of an assailant who approached her vehicle, fired a gun and blew himself up. But we do seem to be getting explanations that are either very contradictory or are explanations that the authorities in question probably can't know. With no post-mortem examination and the body already in the grave, it seems increasingly unlikely we ever will.