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<a href="https://www.washingtonpost.com/graphics/2020/national/george-floyd-america/health-care/">George Floyd </a>was not in the best of health when he encountered police officer <a href="https://www.washingtonpost.com/national/derek-chauvin-george-floyd/2021/03/05/cd6d37b8-782e-11eb-948d-19472e683521_story.html">Derek Chauvin </a>on a South Minneapolis street corner shortly after 8 p.m. on May 25.

At 46, Floyd had three severely narrowed coronary arteries, including one that was 90 percent blocked, autopsies show. His heart was slightly enlarged, probably the result of long-term high blood pressure.

Floyd was a smoker, and he had spent years using street drugs. On that evening, the autopsies reveal, Floyd had a large amount of fentanyl, a small amount of methamphetamine and THC — the active ingredient in marijuana — in his blood.

The video of Floyd gasping for breath and dying beneath Chauvin’s knee that evening <a href="https://www.washingtonpost.com/race-america/?itid=lb_the-derek-chauvin-trial-what-you-need-to-know_8" target="_self">ignited a social justice movement</a> and nationwide demand for policing reform. But when Chauvin’s trial for his alleged role in Floyd’s death begins, much of the argument will center instead on the autopsy details, most specifically whether fentanyl and underlying health conditions — not the police officer’s actions — stopped Floyd’s heart and lungs.

[George Floyd’s America: Examining systemic racism and racial injustice in the post-civil rights era]

Seven experts in toxicology, cardiology and illegal drug use consulted by The Washington Post largely disagreed with that idea, most of them strenuously. All but one said the autopsy findings and other court documents, coupled with the well-known chain of events that evening, made death by a fentanyl overdose unlikely to impossible. (One expert, Craig Beavers, chair of the American College of Cardiology’s cardiovascular team section, said he did not have enough information about all the circumstances to form a final conclusion.)

“From my review of the video and the autopsy report, I see nothing that makes me think he died of an opioid overdose,” said Kavita Babu, chief opioid officer and chief of the Division of Medical Toxicology at UMass Memorial Health Care in Worcester, Mass. Instead, she and others said, the defense uses events out of order and medical findings out of context to deflect blame from Chauvin to Floyd.

Two autopsies — one by a county medical examiner and another by a private medical examiner hired by Floyd’s family — as well as a review by military experts conducted for the federal government, reached the conclusion that Floyd died of cardiopulmonary arrest as the officers subduing him compressed his neck and chest.

Andrew Baker — the medical examiner in Minnesota’s Hennepin County, who is expected to be a key witness in the trial — formally declared Floyd’s death a homicide in June, listing “cardiopulmonary arrest complicating law enforcement subdual, restraint, and neck compression” as the cause of death.

The report listed heart disease, fentanyl intoxication, recent methamphetamine use and Floyd’s bout with the <a href="https://www.washingtonpost.com/coronavirus/" target="_blank" class="contextual_link">coronavirus</a> as other “significant conditions.”

The analysis also found other health issues, including sickle cell trait. People who inherit one gene for sickle cell disease and one normal gene have sickle cell trait. They generally do not have any symptoms of the disease but can pass the trait to their children, according to the Centers for Disease Control and Prevention.

Those findings have given Chauvin’s attorney, Eric J. Nelson, an opening to argue that Chauvin is not responsible for Floyd’s death. The trial could begin as soon as March 29.

[Derek Chauvin: Officer’s aggressive behavior raises questions about excessive off-duty police work]

“Combined with sickle cell trait [and] his preexisting heart conditions, Mr. Floyd’s use of fentanyl and methamphetamine most likely killed him,” Nelson wrote in an Aug. 28 court filing that unsuccessfully sought dismissal of the charges against Chauvin, which include second-degree murder. “Adding fentanyl and methamphetamine to Mr. Floyd’s existing health issues was tantamount to lighting a fuse on a bomb.”

The defense strategy rings of earlier, successful attempts to blame drugs in police violence against African Americans. In 1992, when four Los Angeles police officers were acquitted of the videotaped beating of motorist Rodney King, one testified of fears that King was on PCP, a drug the officer contended gave King “hulk-like strength.” No PCP was found in King’s system.

“Using drugs to justify harsh policing has a long history in the United States,” said Jon Zibbell, a senior scientist at the think tank RTI International, who studies illicit drug use and public health. “And it’s worked.”

The effects of fentanyl and methamphetamine

Citing footage from Officer Thomas Lane’s body camera for most of his argument, Chauvin’s attorney recounted in court papers that the well-known events from last spring began when Lane and his partner, J. Alexander Kueng, approached Floyd’s car. The rookie officers were investigating a complaint that Floyd had allegedly passed a counterfeit $20 bill in a nearby convenience store, Cup Foods.

Nelson declined a request for an interview.

“A white object was visible in Mr. Floyd’s mouth,” Nelson wrote. “At one point, Mr. Floyd turned away from officers, and when he faced them again, the white object was no longer visible.”

Two other people in the car with Floyd, which was parked outside Cup Foods, told police that Floyd was a habitual drug user, and both later said they believed Floyd “was under the influence of narcotics,” according to the court papers. Floyd had been previously arrested for drug possession.

One of the car passengers, Morries Lester Hall, said Floyd quickly fell asleep in the driver’s seat upon returning from the minimart, according to Nelson’s filing. That could have been a sign of use of illegal fentanyl, a fast-acting sedative and powerful painkiller that produces feelings of euphoria.

The police also suspected that Floyd was using drugs. As Lane and Kueng walked Floyd from the car to a sidewalk, they observed him “acting erratically” and repeatedly asked whether he was drunk or “on something,” according to the court papers.

[Police were a part of George Floyd’s life from beginning to end]

They also saw foam coming from Floyd’s mouth, which he explained by saying he had been “hooping earlier.” Nelson, citing the online Urban Dictionary, contended that this is an admission by Floyd that he had ingested drugs rectally.

During court proceedings on another matter Monday, Nelson asserted for the first time that fragments of a pill with Floyd’s DNA on it were found in the back of the squad car. The fragments contained methamphetamine and fentanyl, he claimed. Prosecutors acknowledged the existence of the pill fragments and that they contained methamphetamine, but they did not address the other claims.

The Minnesota attorney general’s office, which is prosecuting Chauvin, has a very different view of  events. If Floyd had anything in his mouth, it was probably chewing gum, Assistant Attorney General Matthew Frank and private attorney Neal Katyal wrote in a Sept. 18 response to the defense’s claims.

The “foam” around Floyd’s mouth was probably spittle, they said, and “hooping” was a reference to playing basketball, which Floyd often did. They also noted Nelson’s conflicting claims that Floyd had taken drugs orally and rectally. The prosecutors did not respond to a request for an interview.

[George Floyd had long seen sports as his path out of the poverty, crime and drugs of Houston’s Third Ward.]

The biggest problem for the defense argument is that events that evening don’t fit a fentanyl overdose, experts said.

“I’m skeptical of the notion of opioid overdose as the cause here,” said David Juurlink, head of the Division of Clinical Pharmacology and Toxicology at Sunnybrook Health Sciences Center in Toronto. “The sequence of events isn’t characteristic of opioid overdose.”

Fentanyl kills by shutting down the part of the brain that controls respiration. Breathing slows, then stops, followed by the heart.

If Floyd had ingested an opioid and fell asleep on his way toward an overdose death, several experts told The Post, he wouldn’t, or couldn’t, have spent the next 20 minutes coherently interacting with police, repeatedly describing his claustrophobia and anxiety, battling with them as they tried to put him in a squad car and struggling against the three officers who pinned him facedown on the street. Instead, he would have become even more sluggish on the path toward unconsciousness and death, these experts said.

“It’s just complete garbage to call it an overdose,” said Kimberly Sue, medical director of the Harm Reduction Coalition, a national advocacy group, and a Yale School of Medicine instructor. In an opioid overdose, “a person is basically blue, unresponsive. … It happens usually from the moment people use to 10 minutes.”

Others noted there is no evidence that police or emergency medical personnel who later arrived used the fast-acting opioid antidote naloxone on Floyd, most likely because they did not believe he was showing signs of an opioid overdose. Both carried the medication, with the United States in the midst of the worst drug epidemic in history. Naloxone can be administered by injection or nasal spray.

“Overdose deaths shouldn’t occur in front of trained first responders” who arrive in time, Babu said.

Instead, when Floyd lost consciousness and police could no longer find his pulse, the officers discussed rolling him onto his side to revive him, which Chauvin rejected in favor of waiting for medical personnel. The police also refused the help of an off-duty firefighter who came to the scene before an ambulance arrived.

The experts agreed that the amount of fentanyl found in Floyd’s blood was very high, at 11 nanograms per milliliter. Lewis Nelson, chief of the Division of Medical Toxicology for Rutgers New Jersey Medical School, said that amount indicates enough to cause a fatal overdose in someone taking the drug for the first time. The analysis was conducted by NMS Labs, a Pennsylvania company.

But Floyd was a longtime fentanyl user — Chauvin’s defense called him an “addict” — who probably had built a tolerance to the drug and could consume larger-than-average amounts without overdosing, experts said. Longtime opioid users often need to take increasing amounts of the drug to achieve the same level of euphoria.

The ratio of fentanyl to one of its by-products, norfentanyl, in Floyd’s blood is consistent with chronic use rather than an acute overdose, Babu said.

The amount of fentanyl in Floyd’s blood also provides only one piece to an overall puzzle, they said. Toxicology is not nearly as precise as it appears on television crime shows. After death, the amount of drug in the blood can increase dramatically, as substances move from organs and viscera into the bloodstream, a point the prosecution raises in its legal papers. The amount found in overdose victims varies widely.

In this case, lab records show that the analysis was performed on blood taken from Floyd at 9 p.m., less than an hour after the confrontation began, as hospital personnel were presumably working to save his life. The records note that the tests were performed on this “hospital blood,” which likely makes them more accurate than blood recovered the next day during the autopsy.

Defense attorneys for Chauvin and the other officers have nevertheless seized on the toxicology findings and Baker’s subsequent comments to prosecutors about those results.

[FAQ: What you need to know about the trial]

According to notes of a meeting between Baker and prosecutors that have been filed as evidence in the case, the medical examiner told them that if Floyd had been “found dead at home alone and no other apparent causes,” it would have been “acceptable” to call his death an overdose. But, Baker added, “I am not saying this killed him.”

Nelson, the toxicologist, said “it is not inconceivable” that fentanyl caused some respiratory depression in Floyd, but the drug’s impact cannot be considered separately from the officers’ behavior. Had Floyd been alone, he “probably wouldn’t have died,” Nelson said.

“If you’re not breathing well because you have respiratory depression, adding compression to the chest and neck is certainly going to contribute,” he said.

Street-drug users often combine fentanyl with methamphetamine, Zibbell said, believing that the stimulant and the depressant balance each other. But experts said the amount of methamphetamine discovered was very small.

Chauvin’s attorney contends the presence of both fentanyl and methamphetamine in Floyd’s blood is evidence of the dangerous practice of taking the two drugs together, known as “speedballing,” which can present the risk of “death from stroke, heart attack, aneurysm, or respiratory failure.” He also cited Baker’s remarks to the FBI that methamphetamine can be “bad for your heart.”

Nelson, the toxicologist, said the small amount of methamphetamine in Floyd’s blood indicates he took the substance a day earlier or perhaps the same morning, not in combination with fentanyl at the scene. Methamphetamine remains in the body for about three days, he said.

Floyd's underlying health problems

At 6’4” and 223 pounds, according to the county’s autopsy, Floyd was an imposing figure. Beneath his exterior, however, he had several health problems. In addition to his clogged arteries, the examination showed, he had sickle cell trait, high blood pressure and a small tumor in his abdomen, none of which was involved in his death, according to the experts and the autopsies.

Floyd had a coronavirus infection less than two months earlier, but it, too, was not considered a factor in the outcome, according to the autopsies and the experts.

The autopsy found that Floyd’s lungs contained fluid, which can be caused by fentanyl, but that kind of buildup is also the result of CPR, which paramedics performed when they arrived and presumably continued into the hospital. The attempt to resuscitate Floyd also fractured one of his ribs, according to the county autopsy.

Geoffrey Barnes, an assistant professor of cardiovascular medicine at the University of Michigan Medical School, expressed concern over the narrowing of three of Floyd’s coronary arteries. One was 90 percent blocked and two others were narrowed by 75 percent.

“Once you get a blockage that’s more than 70 percent, that’s when we start to say in times of stress, you might not get enough blood flow to your heart,” Barnes said. “It’s feasible that when put under stress, his heart could have gotten ischemic, not having enough blood flow, and he went into arrest.”

Video from the scene shows that Floyd was highly agitated, almost panicky, as the confrontation began and remained under stress until he fell unconscious.

[Racism’s hidden toll: The physical and mental strain of a lifetime confronting racism surfaced in George Floyd’s final years]

Barnes said fentanyl could, theoretically, lower Floyd’s blood pressure to the point that oxygenated blood was no longer able to flow through the clogged arteries to his heart. But the sequence of events again makes that much less likely than cardiac arrest as a result of the pressure on his neck and back, he said.

Floyd, Barnes noted, was walking and talking, then struggling with the officers, before he was pinned to the ground.

“I always ask: Why did it happen at that moment?” Barnes said. “Why didn’t his breathing stop two minutes earlier?”

Defense attorneys also have pointed to Baker’s July interview with the FBI, which was not recorded. According to the FBI summary, agents said Baker told them Floyd’s heart and lungs had stopped “due to the combined effects of his health problems as well as the exertion and restraint involved in Floyd’s interaction with police prior to being on the ground.”

The summary says Baker told the FBI that other factors had contributed to Floyd’s cardiopulmonary arrest, including existing heart disease and the presence of fentanyl and other intoxicants.

“Baker did not know if Floyd would have lived but for the officer’s actions,” the FBI summary reads. But the medical examiner told agents that along with the other factors,  “the stress from the events that occurred with Minneapolis police officers was more than Floyd could tolerate.”

Baker also told prosecutors he found “no bruising” on Floyd’s neck or damage to muscles or the structure around the neck, a detail the defense cites as proof Chauvin had not intended to “inflict harm” on Floyd.

“Mr. Chauvin was cautious about the amount of pressure he used to restrain Mr. Floyd — cautious enough to prevent bruising,” his attorney wrote.

Prosecutors contend that bruising is irrelevant because the autopsy has determined that the police subdual of Floyd was a cause of his death.

[Boarded up and lined with barbed wire, Minneapolis braces for murder trial]

Now Baker is poised to tell the story publicly at trial. Jury selection began this week in a courthouse surrounded by concrete barricades and high fencing topped with barbed wire, amid fears of fresh civil unrest in a city still scarred by last year’s violence.

A few blocks away, in the shadow of the city’s shiny glass NFL stadium, an equally tall fence with razor wire and concrete barricades had been installed around an otherwise unremarkable one-story concrete office building — the medical examiner’s office.

George Polk Award for medical reporting, 2017

University of Michigan, BA in American culture, 1979

Lenny Bernstein is a former staffer who covered health and medicine. He started as an editor on The Washington Post’s National desk in 2000 and has worked in Metro and Sports.

Lenny Bernstein

2016 Oklahoma Book Award

2017 American Meteorological Society Lewis J. Batten Award for Distinguished Reporting

2017 Deadline Club Award for Feature Photography

2021 World Press Photo Interactive of the Year

2024 Pulitzer Price for National Reporting 

The Mercy of the Sky

University of Oklahoma

Holly Bailey is a national correspondent for The Washington Post based in Atlanta and covering the South. She joined The Post in 2019 as a national political reporter covering the 2020 presidential campaign. She was part of The Post team that won the 2024 Pulitzer Prize for National Reporting for a series examining the rise of the AR-15.