What Happened to Otto Warmbier?

What we know of the medical case of the young American who was imprisoned in North Korea

Otto Warmbier in Pyongyang in 2016 (KCNA / Reuters)

After being imprisoned for 17 months in North Korea, 22-year-old Otto Warmbier was returned to his home in Ohio this week.

On Thursday, doctors at Cincinnati Medical Center spoke publicly about his condition. It is, technically, “stable”—though that could sound misleadingly positive. His heart is not in imminent danger of stopping, but stability does not mean Warmbier is poised to lead a life that involves movement or communication.

Rather all evidence presented by his doctors yesterday indicates that Warmbier is much closer to death than he is to the University of Virginia student he was in early 2016, when he took a recreational trip to Pyongyang. There he was arrested in the airport for a “hostile act” against the government and last seen shortly after, in the news conference pictured above.

His doctors yesterday described Warmbier’s most recognizable sign of life as “spontaneous eye-opening and blinking.” That means not only is he not communicating, he does not open or close his eyes when asked to do so. He does not show signs of awareness.

Based on magnetic resonance images of Warmbier’s brain, his status is not likely to substantively improve. The scans showed “extensive loss of brain tissue in all regions of his brain.” That means his brain was deprived of oxygen and/or blood for a long time, and tissue died everywhere—much the same process that happens to brain cells in a particular area of the brain when a person has a stroke, everywhere.

This MRI also makes it possible to say whether a stroke is recent or not. People in early stages of hypoxic-ischemic brain injury sometimes improve; people in remote stages do not. Warmbier’s brain injury is in a remote stage. His doctors reported that it happened more than a year ago.

What caused this type of diffuse cellular death throughout the entire brain?

Otto Warmbier speaking at a news conference in Pyongyang in an undated photo released by North Korea's Korean Central News Agency (KCNA) on February 29, 2016 (KCNA / Reuters)

This can be the result of asphyxiation, including by exposure to poisonous gas, and by cardiac arrest of innumerable possible causes. The doctors reported yesterday that the most likely caused was “cardiopulmonary arrest.” That isn’t much of a hypothesis—almost begging the question, in that it means his heart and/or lungs ceased to supply his brain with oxygen.

The real question would be what the doctors believe to be the cause of said cardiopulmonary arrest. They said there was no evidence of trauma, including scars or fractures, which would be evident in imaging tests even after they’ve healed. Even in the hands of forensic pathologists, the exact etiology may never be known with certainty. Though no obvious explanation involves humane treatment and attentive medical care. Even if the 22-year-old simply suffered a (very rare) cardiac arrest of some organic cause, brain injury this severe would mean that he was not resuscitated for a prolonged period.

The explanation that came from North Korea was that the cause was a combination of botulism and ingesting “sleeping pills.” The food-born botulism toxin would not directly account for the damage to the brain. Rather, it paralyzes the muscles of the body, and that can involve the thorax to such a degree that it will stop a person’s breathing. This is a common cause of death in people with untreated botulism. The Ohio doctors said yesterday there was “no evidence” the young man had botulism—though if this happened a year ago, the toxin would be gone from his body and no evidence may remain.

Overdosing on a sedative or opiate could also suppress a person’s breathing to the point that brain tissue dies. The combination of explanations is not implausible.

But neither is it exculpatory. Botulism is treatable; an antidote to the toxin can be administered. Even in the absence of that antidote, cardiac resuscitation and ventilatory support can supply blood to the brain of an acutely paralyzed person.

Yesterday Warmbier’s father Fred described his son as “a fighter.” Evidence provided by his doctors paints this medical case as one where an opportunity for fighting is passed. The bleak prognosis accords better with what Fred said of the plan for Otto: “We’re trying to make him comfortable.”