Abstract
Workshop: The Role of the Medical Examiner in Support of Transportation Accident Investigations – An End-User's Perspective
The mission of the Federal Aviation Administration (FAA) and the National Transportation Safety Board (NTSB) is to advance aviation and transportation safety. As part of that mission, medical professionals at the FAA and NTSB are charged with investigating whether medical conditions or their treatment contributed to the cause of accidents. The detailed autopsies and toxicological analyses we receive from medical examiners supply critical data in support of these investigations. In addition, the described injury patterns are used to improve vehicles' crashworthiness and reduce the risk of death or injury when an accident happens. This panel presentation will review current practices and protocols used by the FAA and the NTSB during medical investigations. The panel will discuss challenges medical examiners may face while assisting transportation accident investigators and present cases highlighting the essential role medical examiners play in transportation accident investigations. FAA and NTSB presenters will cover: Autopsy coordination: The legal “nuts and bolts” of transportation autopsies, how the FAA autopsy program assists investigators with coordinating autopsies and obtaining autopsy reports. Pilot medical case review: Physician review of FAA medical certification records and sharing of known, pre-mortem medical conditions with medical examiners. Toxicology: The role of the FAA's Toxicology Laboratory in transportation accidents, why the FAA/NTSB conducts a separate analysis, issues with the TOXBOX, and common toxicological findings in fatal transportation accidents. Autopsy data and the probable cause: The autopsy as an investigative tool; critical details beyond the manner and cause of death; determination of underlying natural disease that may have incapacitated a pilot or degraded his or her judgment or cognitive skills: such as acute coronary events and hemorrhagic stroke. Autopsy data and crashworthiness: The role of autopsy data in assessing aircraft safety system design: the effectiveness analysis of crash-worthy fuel systems in various helicopters. These presentations will describe current practices and demonstrate to medical examiners how their work continues to enable improvements in transportation safety. This panel discussion will also be an excellent opportunity to discuss what the FAA/NTSB can do to help medical examiners and how medical examiners can assist FAA/NTSB investigators.
Federal Aviation Adminstration, Oklahoma City, OK
National Transportation Safety Board, Asburn, VA.
The Recovery of the Fallen - the Investigation of WW1 Mass Graves at Fromelles in Northern France
The battle of Fromelles in July 1916 was responsible for the single largest loss of life in one day in the history of the defense of Australia. Following a disastrous attempt to divert the Germans from the front line at the Somme, several brigades of British and Australian soldiers were slaughtered by German artillery and machine gun fire. To this day, many bodies of the dead Allied soldiers have never been recovered. In 2008 after an exhaustive investigation by private and university-based archaeologists and military historians, the site of several mass graves was identified in the village of Fromelles, near Lilles in northern France. In the following year, with support of the Commonwealth War Graves Commission, these graves were examined and excavated and the bodies of the soldiers that had been interred in them were exhumed. This presentation will describe how the graves were identified and examined and will outline the process by which the skeletal remains were removed. The project team used full forensic archaeological techniques so that as many of the dead as possible could be identified before being re-buried in marked grave sites in an adjacent brand-new Commonwealth War Cemetery. A temporary mortuary was constructed close to the site of the mass graves and this mortuary incorporated facilities for radiology, processing of the skeletal remains, photography, and examination of forensic artefacts as well as full anthropological analysis. Forensic samples were taken from each set of remains and were subjected to DNA comparison with reference samples that had been collected from various family members, many of whom were several generations removed from the deceased. 250 individual bodies were exhumed from the graves, most of whom were found by direct or indirect means to have been Australian. Although the excavation has been completed, the identification program has been continuing since 2009 as more families come forward to volunteer DNA for comparison. As at 2013, 124 bodies have been fully identified and 98 further identified as being Australian but without individual names. The program will be finalized in mid 2014.
Queensland Health Forensic and Scientific Services, Buderim, Australia.
The Investigation of a Cluster of Mixed Fentanyl and Heroin Overdose Deaths: How the Use of Epidemiologic Surveillance Resulted in the Rapid Identification and Enhanced Monitoring of a Public Health Crisis
Deaths due to drug overdose crisis in the United States have increased significantly over the past 20 years and now exceed the number of deaths each year from traffic crashes. Such deaths can occur in temporal and geographic clusters because of variations in the toxicity and distribution of the various types of illicit and licit drugs that are abused. Two barriers to the rapid identification of an “outbreak” of overdose deaths are 1) the lack of a standardized and sensitive methodology for outbreak identification and investigation, and 2) a delay between a suspected overdose death and complete toxicology results due to administrative and/or physical separation of toxicology and drug chemistry section of crime laboratories. We report here on an outbreak of combined fentanyl and heroin overdose deaths in Allegheny County, Pennsylvania. First, the recognition of a potential outbreak was apparent from the excess number of overdose deaths occurring in the timeframe of interest. Next, evidence was collected and categorized in a shared spreadsheet, including: the toxicological data from the overdose deaths and the chemical analysis of drugs seized from both death scenes and by law enforcement entities, demographic and geographic distribution of the deaths, and other relevant information. In this instance the offending agent was rapidly revealed to consist of a distinctive pure white powder comprised of an equal mixture of fentanyl and heroin. A categorical comparison of frequencies was made for all of the significant information in order to identify meaningful patterns among the deaths. The results were as follows: 14 overdose deaths occurring over a 12 day period. The drug mixture was contained in small glassine envelopes known as “stamp bags.” These stamp bags were either supplied to end users by drug dealers or seized by law enforcement and submitted to the Drug Chemistry section of the laboratories. Although more than 20 varieties of stamp bags were commonly found in the community at the time of the outbreak, the distinct fentanyl/heroin mixture was only found in 2 types of the bags. The methods described in this investigation are standard practices employed in the epidemiologic investigation of the outbreak of food and blood borne illness described here could be standardized for use on a wider basis nationally. Given adequate resources the experience could be developed into a continually updated data analysis that might both follow trends in overdose deaths as well as detect developing threats.
Office of the Medical Examiner of Allegheny County, Pittsburgh, PA
Oregon Health & Science University, Portland, OR.
The Design of a New Mortuary and Medical Examiner Facility in Abu Dhabi
Abu Dhabi is the wealthiest of the seven emirates that make up the state known as the United Arab emirates. Currently the death investigation system is extremely limited with no forensic pathologists in the emirate. Last calendar year 36 autopsies were performed in an antiquated facility which is a refitted cafeteria. While this emirate is predominantly Muslim, nine out of 10 of the individuals living within the emirate are foreign workers. This provides a rich and diverse cultural and religious population. The present mortuary is under the control of the Abu Dhabi police department. They, in conjunction with the health department, have formed a mortuary committee to construct a new facility and establish a modern western based medical examiner system. In Abu Dhabi there are no private funeral homes. It is considered a state function to prepare the body for appropriate disposition. This may vary from traditional Muslim washing and shrouding and rapid burial to full embalming an international transportation for a non-citizen. These tasks will also be undertaken in the same mortuary facility as the medical examiner system. There is no death investigation infrastructure on which to base scientific criteria for a new facility. Extensive study was done into the population makeup, growth and applying modern medical examiner criteria recommendations were made to the mortuary committee for a new facility. This paper will describe the overview and study process, an overview of the present medico-legal death investigation system, the unique additional facility requirements for a Muslim country. Additional discussion on the project location, program elements and early conceptual diagrams will be presented.
SmithGroupJJR, Phoenix, AZ
Office of the Chief Medical Examiner, Baltimore, MD.
Case Resurrected - Justice Unserved: The Investigation into the Death of LCpl Billy Joe Wyatt, USMC: Vietnam War 1968
The case to be presented involves the death of LCpl Billy Joe Wyatt, USMC who died during the Battle for LZ Torch (Quang Tri Province of Vietnam) on the morning of 11 June 1968. The case of LCpl Wyatt was brought to the attention of NCIS (Naval Criminal Investigative Service) in 2009 by Michael Hoskins, writer and former Marine, while conducting research for an article he was writing entitled “The Battle for LZ Torch.” Interviews of two US marines who were present at the Battle for LZ Torch, revealed that they witnessed their commanding officer, a Marine Lt, draw his issued .45 caliber sidearm and shoot LCpl Wyatt. In 2010 the author received a request from NCIS HQ to review the case file of LCpl Wyatt and to opine as to whether there was sufficient evidence to warrant the exhumation and examination of the remains, some 42 years after his death. After a review of the case file the author informed NCIS that an exhumation was warranted, and that recovery of pertinent forensic evidence may be possible, even though the remains most likely will be in a skeletonized state and poorly preserved. In December of 2010 the exhumation of LCpl Wyatt took place, at which time it was discovered that LCpl Wyatt had been buried within a heavy steel dome vault rather than the typical concrete vault. Once the coffin was breached it exposed a full length glass plate with a reinforced steel frame which had been welded to the top of the casket. Through the glass cover, to our amazement, one could see the uniformed and immaculately preserved body of LCpl Wyatt, appearing as he did on the day of death. Detailed examination of the body including CT and standard radiographic imaging revealed evidence of a single bullet wound which entered the left cheek fracturing the base of the mandibular ramus and passing downward through the neck into fracturing the fifth, sixth and seventh cervical vertebra. At the terminal point of the bullet tract, located within the right shoulder just above the scapula, a .45 caliber copper jacketed bullet was recovered. At the present time the investigation has stalled, which may be a politically motivated example of not opening “a past war time incident” as it would be an embarrassment to the military and detrimental to the reputation of an aged but highly decorated Marine officer.
Office of the Chief Medical Examiner State of Maryland, Baltimore, MD.
An Unrecognized Patricide: A Representative Case of the Italian Death Investigation System
Patricide (killing the father) is one of the most heinous crimes and a rare form of homicide. Usually the assaults occur at home in the absence of witnesses and adult sons are frequently involved. This presentation will show a case of patricide originally misclassified as accident because of the death investigation not run professionally and performed only by external body examination with relevant discrepancies about interpretation between minor external trauma lesions and manner of deathThe story begins when the body of a 60 year old lady was found on the bloody floor of her stationary store. At autopsy cause of death was related to stab wounds to the neck and blunt injuries to the head with skull fractures as the resultt of multiple blows with a hammer. The murder suspect was her son-in-law, a 40 year old man who first discovered the corpse and called the emergency service. Based on the evidence collected by blood pattern analysis on the scene and on the blood-stained clothing worn by the suspect, the man was found guilty. But the investigation raised also the possibility that an additional victim could have been killed by the suspect. In fact, this was the second time the man found a cadaver. Three years before, the suspect found his 70 year old father dead at the bottom of a bloody basement stairwell at home. The day after death, a preliminary external body examination recorded several stab wounds to the right side of the neck and thorax and a forensic autopsy was requested. Surprisingly the Prosecutor requested an additional external body examination without subsequent autopsy. This second survey performed by a general pratitioner certified that all the injuries were consistent with a blunt trauma occurred falling down stairs. Therefore, the case was ruled as accident. Only the exhumation of the father, performed years later, confirmed the diagnostic hypothesis raised by the first physician. The elderly man had received multiple stab wounds to the neck and thorax. The 40 year old son was finally condemned to life in prison for double murder. He never confessed to the crimes. This is a representative case of the Italian death investigation system commonly performed by individuals with no specific training where most of the medico-legal investigations (especially for deaths resulted from rauma) are restricted to an external body examination without subsequent autopsy.
University of Molise, Campobasso, Italy
University of Bari, Bari, Italy.
“Razors pain you,…Nooses Give”: Lessons from the Planned Complex Suicide of a Surgeon
A 60 year old male paediatric maxillofacial surgeon, facing imminent indictment and loss of licence in a sexual offense matter, apparently committed suicide by near-simultaneous full-suspension hanging and a lethally-situated single stab wound of the chest. This represents a planned complex suicide, the definition and significance of which will be discussed. The true extent of the planning was apparent at autopsy, and will no doubt be identified by the astute attendee of the presentation. This case is unusual as a suicide but also unusual within the context of suicide by physicians in terms of method and presumed risk factors, which will be briefly explored. Another issue raised by this case was unexpected positivity for HIV infection on screening. The significance of this in a medical practitioner who necessarily performs exposure-prone procedures, the role of the autopsy in light of this finding, and the potential benefit (and logistical complications) of neuropathological examination in this situation will be discussed. DNA cross-contamination is a concern in all forensic institutions. The investigation into how the deceased's DNA profile emerged on a wrist swab of a homicide victim who was autopsied almost a week later will be presented.
Department of Forensic Medicine Sydney, Glebe, Australia.
Death and the Art of Frida Kahlo: Illustrations of Forensic Pathology
The Mexican painter Frida Kahlo (1907–1954) endured various health problems in her lifetime. She confronted the fragility of her health early in life when she contracted the poliomyelitis virus at six years of age. Although the physical sequelae of the poliovirus caused her much embarrassment, the observations of her disease helped to initiate an interest in biology and medicine. Having survived poliomyelitis, Kahlo wanted to become a physician and pursued premedical coursework as a teenager. A near fatal streetcar accident at eighteen years of age, however, changed her outlook on life and she decided to no longer pursue a career in medicine. While recovering from her traumatic injuries, Kahlo began to paint and an interest in art quickly emerged. In addition to her self-portraits, Kahlo is recognized for paintings that depict her physical and mental pain. To illustrate her struggles with pain, Kahlo utilized medical imagery and juxtaposed themes of life and death. In a number of her works, Kahlo focused on the event of death and even shared visions of her own death. Closer examination of her works reveals that Kahlo illustrated each of the categories of death recognized by American medical examiners and coroners: natural, accident, suicide, homicide, or undetermined. By portraying the categorical multiplicity of death in her paintings, Frida Kahlo created a collection of artwork that reflects the post-mortem cases encountered in forensic pathology.
Los Angeles County Department of Medical Examiner-Coroner, Los Angeles, CA.
Snake Bite Deaths in South East Queensland, Australia
Australia is home to many venomous snakes, including some of the most poisonous species in the world. Although found predominantly in bushland areas, some species also invade urban areas with resultant increased risk of snake bite to humans. Fortunately, due to good medical treatment, including the use of anti-venom, fatalities are rare and frequently due to unusual circumstances. Two fatal snake bites cases which occurred in South East Queensland during the summer of 2013 are reported. The first case was 72 year old man in a semi-rural area who was bitten by a snake, subsequently identified as a brown snake. Following a delay in seeking medical treatment, he was admitted to hospital with severe coagulopathy which did not respond to anti-venom and blood products. He developed an intracerebral hemorrhage which was ultimately fatal. The second case was a 64 year old man who was initially admitted to hospital following a traffic collision in which he sustained chest injuries. He was found to have a severe coagulopathy and was subsequently diagnosed as having suffered envenomation by reptile from the tiger snake group. He was unable to receive anti-venom due to prior sensitisation, but was given blood products. He developed multi-organ failure and died several days later from a combination of direct complications from the snake bite and excessive hemorrhage from his chest injuries. The clinical and pathological features of snake envenomation will be discussed with specific reference to these cases.
Queensland Health Forensic and Scientific Services, Health Services Support Agency, Southport, Australia.
Drug Deaths and Autopsy Access: A Potential Missing Link in Public Health Surveillance
University of North Dakota, Grand Forks, ND
North Dakota Department of Health, Bismarck, ND
State Forensic Examiner, Bismarck, ND.
MDMA Use, Intercourse and Aneurysm Rupture
A 26-year-old previously healthy man died suddenly and unexpectedly during sexual intercourse. The autopsy showed a ruptured berry aneurysm of the middle cerebral artery of the Circle of Willis resulting in a subarachnoid and intraparenchymal hemorrhage. Post mortem toxicology was positive for 3,4-methylenedioxymethamphetamine—MDMA, or “ecstasy.” Our search of the literature has revealed that MDMA abuse and sexual activity have both been associated with fatal and non-fatal subarachnoid hemorrhages secondary to rupture of berry aneurysms. We did not find in the literature any reports of fatal cases which include both risk factors (MDMA abuse and sexual activity) present simultaneously. The authors describe salient features of MDMA and berry aneurysm, and the relationship between MDMA, berry aneurysm and sexual intercourse.
William Beaumont Hospital, Royal Oak, MI
Wayne County Medical Examiner, Detroit, MI.
Quality Assurance of Manner of Death Classification via Benford's Law: How to Practically Apply?
McMaster University, Hamilton, Canada
Stanford University, Palo Alto, CA.
SUID: How Multidisciplinary Collaboration Can Inform Diagnosis and Prevention
Attendees will learn how a medical examiner's office and a public health agency can collaborate to: 1)· Evaluate sudden unexpected infant deaths in a timely manner; 2 Collect quality data that will assist in making consistent diagnoses; 3) Provide data to the Centers for Disease Control and Prevention's (CDC) Sudden Unexpected Infant Death (SUID) Case Registry initiative to monitor trends and characteristics associated with SUID; and 4) Develop actionable prevention strategies through multi-disciplinary case review. The New Hampshire Office of Chief Medical Examiner (OCME) in partnership with the Department of Health and Human Services' Maternal and Child Health (MCH) Section, is one of nine grantees funded by CDC to participate in the National Center for the Review and Prevention of Child Deaths' web-based data registry, a public health surveillance system that collects information regarding the circumstances and events surrounding sudden unexpected infant deaths. Cause and manner of death can be classified various ways on death certificates. SIDS, unknown, undetermined and suffocation can be listed as the cause of death of infants who die in similar sleep environments. Manners range from natural to undetermined to accident. Inconsistent terminology hinders the ability to monitor national trends. OCME provided investigators with dolls and training in order to have doll reenactments of the death scene. In several subsequent infant death cases, the investigator's interpretation of the caregiver's verbal description of the scene did not match the caregiver's doll reenactment of the scene. Digital images of the doll reenactment have impacted the pathologist's determination of cause and manner of death in some cases. Grant funding provided by the CDC has allowed for the hire of a SUID Project Data Clerk, who is based at OCME. The data clerk reviews the infant's and mother's medical records, the birth certificate, and police reports and inputs that data, as well as information from the death investigator's report and the autopsy report, into the case registry. The MCH project manager coordinates meetings that bring a multidisciplinary group of professionals together to review the circumstances of each death with the goal of using the findings to take action to prevent other deaths. A list of recommendations is generated for each case and the progress of the recommendations is reviewed at subsequent meetings. Data will be reviewed annually to identify and monitor risk factors, and develop focused strategies.
New Hampshire Office of Chief Medical Examiner, Concord, NH.
Spectrum of Coronary Artery Pathology in Pediatric Hospital Autopsy Practice
Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA.
Pushing the Frontiers of Forensic Toxicology - What to Do When Your Mass Spec is No More Valuable than a Paper Weight
State of Maryland Office of the Chief Medical Examiner, Baltimore, MD.
Acute Coronary Artery Thrombosis Associated with Synthetic Cannabinoid Intoxication
Maryland Office of the Chief Medical Examiner, Baltimore, MD
CVPath Institute, Inc, Gaithersburg, MD.
Suicide by Shotgun in Southeastern Minnesota
Mayo Clinic, Rochester, MN.
The Effect of the Great Recession on Medical Examiner Workload
For the years leading up to the start of the Great Recession, the Office of the Chief Medical Examiner for the State of Maryland was seeing an annual increase of between 50 and 125 autopsies each year. The average number of autopsies for the five years preceding the start of the Great Recession is 4111 (2003–2007). The first year of the Great Recession in 2008 showed a significant decrease in the number of autopsies performed in the office. The total number of autopsies performed dropped to 3871. This appeared to be a national trend, and information available online for several medical examiner offices reveals a similar pattern. The categories showing significant decreases in the number of autopsies performed from 2007 to 2013 include motor vehicle accidents, a decrease from 507 to 356. Homicides decreased from 579 to 424. Drug related deaths decreased from 866 in 2007 to 702 in 2011, then peaked again to 872 in 2013 with the economy slowly emerging from the recession. This paper will discuss some of the sociological and correlative factors shaping these numbers, which appear to be reversing as the nation has partially recovered from the Great Recession. The risk of death in a motor vehicle collision is directly related to the number of miles driven. Miles driven during a recession decline because fewer people are working. People have less disposable income and a lack of consumer confidence which results in a reduced likelihood of fatal motor vehicle accidents. The latest report from the Department of Transportation's Federal Highway Commission entitled Traffic Volume Trends reveals a substantial decline in miles driven from 2007 to 2013. The number of individuals entering drug treatment programs was reported to have increased significantly over the study period. The adverse economic climate is perhaps a motivating force behind individuals seeking treatment rather than purchasing drugs on the street. The number of homicides decreased correspondingly to the number of drug deaths. Death by suicide was the only category that showed a reverse trend with an increase from 514 in 2007 to 570 in 2013.
Office of the Chief Medical Examiner, Baltimore, MD.
Postmortem Opioid Levels, Co-Intoxicant Presence, and Decedent Characteristic in Accidental, Single-Opioid Deaths in West Virginia and Northern New England
Despite the frequency of polydrug deaths, there has been little research addressing the complex interrelationships among co-intoxicant drugs, and medical examiners differ in how they certify polydrug deaths. A project funded by the West Virginia Injury Control Research Center (ICRC) and the Centers for Disease Control utilized the Forensic Drug Database (FDD) developed at West Virginia University to capture comprehensive data from all drug-related deaths and expand coverage to include northern New England states. We report a study of 1556 accidental deaths involving single opioids with co-intoxicants in West Virginia, Maine, New Hampshire and Vermont, 2007–2011. We modeled the relationships between opioid levels and the presence (as determined by the death certificate and verified by toxicology) of co-intoxicant benzodiazepines, alcohol, tricyclic antidepressants (TCA), selective serotonin reuptake inhibitor (SSRI) antidepressants, and diphenhydramine, along with additional covariates of state, age, body/mass index (BMI), and gender. Single-opioid deaths included those caused by oxycodone (N=497), methadone (N=662), hydrocodone (N=189), and fentanyl (N=208). Co-intoxicant benzodiazepines were present in 715 deaths, alcohol was present in 281 deaths, TCAs were present in 63 deaths, SSRIs in 102 deaths, and diphenhydramine in 72 deaths. For each of the four opioids examined, a multiple regression model was applied to the log-transformed opioid concentrations in order to estimate the association of each co-intoxicant or covariate, adjusting for all other variables. Benzodiazepine presence was associated with significantly lower levels of hydrocodone (p=0.05) and methadone (p=0.03), but was not significantly related to either fentanyl (p=0.12) or oxycodone (p=0.91) concentrations. Alcohol presence was associated with significantly lower concentrations of hydrocodone (p=0.02), methadone (p<0.0001), and oxycodone (p=0.002). TCA presence was associated with significantly lower levels of oxycodone (p<0.0001). Older age was associated with significantly higher levels of methadone (p=0.0004). On average, males had significantly lower levels of fentanyl (p=0.03) and methadone (p=0.01). Higher BMI, SSRI presence and diphenhydramine presence were not significantly associated with the toxicology levels of any of the four opioids. In summary, certain factors, particularly gender, age, and the presence of alcohol, benzodiazepines or a TCA, appear to significantly and differentially affect the concentrations of one or more of the opioids studied.
University of Maine, Orono, ME
West Virginia University, Morgantown, WV
State of West Virginia, Charleston, WV
State of Maine, Augusta, ME
State of Vermont, Burlington, VT
State of New Hampshire, Concord, NH.
Evaluating the Utility of Urine Dipsticks as a Postmortem Triage Modality
Cook County Medical Examiner, Chicago, IL.
Accidental Carbon Monoxide Poisoning While Driving: A Case Report with Review of the Literature
Carbon monoxide may be the cause of a significant percentage of fatal poisonings in many countries. It is known that fatalities resulting from carbon monoxide poisoning are underreported and/or misdiagnosed. Carbon monoxide exposure while driving can occur due to faulty exhaust systems, defective ventilation systems, emission from other vehicles, and even cigarette smoking. We report the case of a 23-year-old woman who was involved in a low-speed motor vehicle collision and was found unresponsive in her vehicle. The woman was the restrained driver of a four-door sedan that crashed into a house in the early morning hours. While she was driving, she spoke to her mother on the phone. She mentioned that she was having car trouble and that she might need to be picked up. The collision caused minor damage to the vehicle and the airbags did not deploy. Law enforcement and emergency medical services responded to the scene, extracted the woman, and conveyed her to the hospital. She suffered minor non-fatal trauma. Her laboratory results were significant for a carboxyhemoglobin level of 44.9% and blood ethanol concentration of 104 mg/dL. A neurological evaluation revealed anoxic brain injury. She remained in the hospital for five days. Due to her poor prognosis, her family withdrew care. An autopsy demonstrated minor abrasions on the face, chest, and back, as well as a contusion on the left arm. There were no internal injuries. The brain was diffusely edematous. Sections of the hippocampus demonstrated anoxic-hypoxic neuronal injury. There was an acute pontine hemorrhage. Subsequent evaluation of the vehicle by a mechanic revealed a broken bolt in the exhaust manifold, as well as an absent exhaust clamp. There were several rusted holes in the undercarriage of the vehicle that allowed exhaust to enter the passenger compartment. There were rusted holes in the top of the muffler, as well as a large rusted hole in the trunk directly above the muffler. These defects lead directly to the carbon monoxide poisoning of the driver. The prevalence of accidental fatal carbon monoxide exposure while driving is rare in the recent era of catalytic convertors. A review of the literature revealed approximately thirty articles regarding carbon monoxide poisoning while driving, few of which are similar to this case.
University of Michigan, Ann Arbor, MI.
Uncommon Complications of Dental Surgery Seen in Forensic Pathology
Dental manipulation is an extremely rare cause of cerebral abscess or meningitis with fewer than sixty reported cases in the literature. Sudden death arising from these complications is even rarer. We report an additional case for the forensic literature of an odontogenic cerebral abscess with concomitant anaerobic bacterial meningitis, confirmed with cultures and special studies. The patient was a 53-year-old male with a history of a recent dental extraction 8 weeks prior to death who was complaining of residual jaw pain with new onset nausea and vomiting prior to his sudden death. Mobility of teeth and periodontal disease was noted at autopsy. The prior tooth extraction surgical site was unremarkable. The remainder of the autopsy confirmed the decedent's medical history of hypertension. The neuropathologic examination revealed purulent meningoencephelitis with ventriculitis and cerebral abscess of the right temporal lobe, located on the same side as the previous dental extraction. Cultures of the leptomeninges and a gram stain of histological sections revealed organisms consistent with Peptostreptococcus and Fusobacterium nucleatum – known oral cavity pathogens. We report a most unusual case of a cerebral abscess in which the dental site is implicated. In this case, the cultures of the leptomeninges around the cerebral abscess in addition to special stains performed of the cerebral abscess identified organisms consistent with dental origin. Our case report appears to be the first in the literature to isolate both Peptostreptococcus and Fusobacterium nucleatum from a cerebral abscess causing death weeks after the prior tooth extraction. Our findings are further supported by the medical literature reporting delayed-onset infections after impacted molar extraction in which the organisms isolated from these infections are the same organisms we observed on cultures and special studies. The decedent's sub acute clinical presentation is consistent with the microorganisms of dental origin being responsible for the delayed-onset infection. Our case underscores the necessity of a careful neuropathic and oral cavity examination to associate the patient's sub-acute dental manipulation and infection with the resulting meningitis and temporal lobe abscess to determine cause of death.
Santa Clara County Medical Examiner Office, San Jose, CA
Santa Clara Medical Examiner, San Jose, CA.
Comparison of the Distribution of Skull Fractures by Mechanism of Formation
University of Alabama at Birmingham, Birmingham, AL
University of Alabama at Birmingham School of Public Health, Birmingham, AL.
The Rabies Autopsy: Beyond the Brain
The rabies virus is a mammalian RNA virus belonging to the Rhabdoviridae family. The virus is transmitted when a person or animal is directly exposed to infected material from a rabid animal. Human infection typically occurs after an animal bite; although rare cases of human-to-human transmission have occurred in organ and tissue transplant recipients. The fear and risk of infection are typically deterrents to performing an autopsy on an individual infected with the rabies virus. The rare instances where one has knowingly been performed, it has been limited to the brain only. While important to document and confirm the presence of rabies encephalitis, it is equally important to identify the other tissues the virus may be found in, which makes the performance of a full autopsy the best practice. We present the case of a young male who was in custody in a series of United States facilities after illegally crossing the border between the United States and Mexico. He became symptomatic while in a detention facility, transported to a local hospital and then transferred to a larger hospital, resulting in a significant potential exposure population. While exhibiting some of the classic signs of rabies encephalitis, he also exhibited some unusual symptoms which will be discussed. The diagnosis was initially made on serum by Enzyme-Linked Immunosorbant Assay (ELISA) at a commercial laboratory and subsequently confirmed on serum and cerebrospinal fluid through testing performed at the Centers for Disease Control and Prevention (CDC). Wearing a full Tyvek suit and utilizing a Powered Air Purifying Respirator (PAPR), a complete autopsy was performed at the Harris County Institute of Forensic Sciences at the request of, and with the assistance of, pathologists from the CDC after obtaining consent by the legal next of kin. Samples were taken of all organs and subsequent testing for the rabies virus was performed at the CDC. The rabies virus was identified in the brain, dorsal root ganglia and small nerves adjacent to the bladder, coronary artery, aorta, salivary glands, tongue, stomach and intestines. Postexposure prophylaxis in the form of human rabies immune globulin combined with four doses of the rabies vaccine is utilized in cases of exposure to the virus. This combination is highly effective at preventing rabies when administered soon after an exposure. The precautions taken during this autopsy were deemed adequate enough to not require postexposure prophylaxis.
Harris County Institute of Forensic Sciences, Houston, TX
Centers for Disease Control and Prevention, Atlanta, GA.
The Washington Navy Yard: Fatality Management in an Active Shooter Response
On September 16, 2013 a lone gunman armed initially with a shotgun, fatally shot twelve (12) people and injured three (3) others in a mass shooting at the headquarters of the Naval Sea Systems Command (NAVSEA, Building 197) inside the Washington Navy Yard in Southeast Washington, D.C. The attack began at 8:16 a.m. EDT. The shooter was killed by law enforcement at 9:25 a.m. EDT. Scene response occurred with the formation of the Office of the Chief Medical Examiner (OCME) Assessment Team that included the Chief Medical Examiner, Chief of Death Investigations, and Lead Forensic Photography. The fatality management plan was properly initiated and the medical examiner jurisdiction established (according to Title 10 of the US Code § 1471). The primary law enforcement team leading the investigation and response was comprised of the DC Metropolitan Police Department in cooperation with the Naval District of Washington Police Department, Naval District of Washington Fire and EMS, Naval Criminal Investigative Service, DC Fire and EMS, US Park Police, and the FBI Washington Field Office. Thirteen (13) individuals were examined and transported from the scene by the DC OCME. Full autopsy examinations were performed on eleven (11) men and two (2) women. All deaths were classified as Homicides. Ten (10) of the twelve (12) victims suffered Shotgun wounds of the head, neck, and/or torso; two (2) victims sustained gunshot wounds of the head; and the gunman suffered multiple gunshot wounds. Fatality Management in the context of the active shooter response has many challenges. These challenges are often unrelated to the determination of cause and manner of death. Communication and relationships with first responder agencies as well as the need for additional equipment were recognized. The identification process proved to have its own challenges but showed itself to be acceptable. The sufficiency of the identification process was largely due to the DC OCME's unique relationship with The Wendt Center for Loss and Healing. Since 1999 the Wendt Center has offered the grief support during the identification process at the OCME. The Wendt Center therapists were instrumental in next-of-kin notifications alongside FBI personnel as well as visual identifications performed at the OCME. Overall, the DC Office of the Chie Medical Examiner's response was well done including the successful implementation of the fatality management plan, the timely identification and release of decedents, and the tireless commitment and professionalism of the OCME staff.
Office of the Chief Medical Examiner, District of Columbia, Washington, DC
The Wendt Center for Loss and Healing, Washington, DC.
Mortality Surveillance, Electronic Death Registration, and the Medical Examiner
With the advent of electronic death registration (EDR) and increasing modernization of traditional, paper-based death registration systems, many advances in the timeliness as well as the utility of death certificate data to identify emerging, transitional, and on-going health threats are being realized. Pilot projects assessing the capacity for near-real time mortality surveillance using death registration systems have shown the tremendous potential for state and national monitoring of certain causes of death. A few notable examples include surveillance of seasonal influenza; surveillance of natural disasters such as tornados and hurricanes; and early identification and confirmation of deaths due to rare vaccine preventable diseases. This presentation will describe the current capacity for using death registration systems to conduct mortality surveillance with a special emphasis on the application to sudden unexpected deaths. In addition, the presentation will explore opportunities to further integrate death registration systems with the operations and data collection processes within medical death investigation offices. Success stories with EDR for mortality surveillance, such as with natural disasters, have involved cooperation between vital records, health departments and offices of medical examiners and coroners. Currently over three-quarters of the states have some form of EDR and others are in the planning or development phase. As the EDR systems mature, the ability to extend beyond simple data input will enhance the ease of use of these systems and facilitate conducting research and collaborative projects. Medical examiners, coroners, and forensic pathologists play a critical role in the timely collection of complete and accurate information on the cause and manner for all sudden and unexpected deaths. Active discussion and input by this community on functional features and processes to facilitate interaction with EDR systems are needed. The existing capacity of the vital statistics system to monitor mortality across causes of death, places of death, and geo-political boundaries regardless of certifier allows real-time monitoring and analysis of new and emerging threats. Use of these systems can potentially result in faster dissemination of information and quicker preventive actions taken to save lives.
National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, MD.
Short Delay in Collapse following Impact in Fatal Traumatic Basal Subarachnoid Haemorrhage
The investigation of a death caused by traumatic basal subarachnoid haemorrhage (TBSAH) is often problematic. The pathologist needs to quickly recognise the nature of the death and approach the postmortem examination in a way that captures the key evidence that will be required for any subsequent medico-legal process. This includes identifying the likely site of impact, the level of applied force and the source of the traumatic bleeding that is almost always within the vertebro-basilar system. When the circumstances of the altercation introduce the possibility of more than one assailant landing a blow to the head or neck, then the pathologist will need to consider which impact precipitated the fatal bleeding. This is especially important when joint enterprise between the assailants cannot be demonstrated. Although rare examples are reported where bleeding has been delayed for a period of hours or days after impact, it is generally accepted that collapse and unconsciousness is immediate. With this in mind, careful consideration of the eye witness accounts can sometimes confidently identify the individual who struck the victim just prior to collapse and was responsible for the death. This paper presents three cases of TBSAH in which a definite very short delay occured between the landing of a final blow and subsequent fatal collapse within the incidents. In two of the cases, the delay was in the order of 10–15 seconds during which both the victims remained standing and in the third, the exact delay was unclear but was very probably less than 30 seconds. During this interval period the victim was able to speak to a witness. These observations indicate that the traditional concept of immediate collapse following impact in TBSAH is not always the situation and that some victims can at least stand or talk, albeit for a very short period, prior to collapse. Given the possibility of the existence of a short delay in collapse within an incident, it is obviously important not to necessarily attribute the fatal bleeding to the last documented blow or impact to the head and neck, without a careful study of the entire case circumstances.
Royal Liverpool University Hospital, Liverpool, United Kingdom (Great Britain).
Sustaining and Saving Life – Understanding Organ and Tissue Recovery
Innovative uses for tissues, both life-enhancing and life-saving, have led to a surge of growth in tissue recovery and transplantation. Forensic pathologists and death investigators play a pivotal role in the success of transplantation as the majority of eligible donors fall under medical examiner/coroner jurisdictions. Designing cooperative policies and procedures to accommodate organ, tissue and cornea recovery will become an increasing aspect of the forensic pathology workflow. Forensic pathologists and death investigators need to have more than a basic understanding of donation but unfortunately, many do not. This two hour workshop will attempt to resolve some of the basic knowledge gaps that exist. First, leading representatives of the American Association of Organ Procurement Organizations (AOPO), American Association of Tissue Banks (AATB), and the Eye Bank Association of America (EBAA) will speak about the transplant process as a whole to include regulatory aspects, challenges, and the future. Second, an overview of the science of transplantation - how it works, the scope of illnesses that can be treated, and the benefit to using human tissues and organs compared to other options will be discussed. Recovery time restrictions, organ versus tissue recovery, possible recovery induced artifacts and available ancillary studies which can be provided, if one knows to ask, are but a few of the important aspects to be discussed. The most advanced, and innovative medical uses of tissue will also be highlighted. Finally, forensic case scenarios that have been solicited from the NAME listserv will be presented in a panel discussion. Actual cases will serve to illustrate real outcomes for donor agencies, death investigators, and donor families while hypothetical cases invite solutions for the future. Many recovery denials by forensic pathologists and death investigators are based on the perceived potential loss of crucial information needed to determine or document cause and manner of death. The hope is for participants to share and understand how common cases are handled quite differently by various forensic pathologists without untoward outcome. Building trusting relationships and cooperation by a mutual understanding of each parties' needs are crucial to sustaining the availability of allografts for patients, while maintaining the integrity of forensic case investigations. The demand for donated organs, tissues, and corneas will continue. Because donation and transplantation has enormous public support and political impact, it will only benefit death investigation systems to be educated and proactive in order to achieve mutually beneficial outcomes.
Santa Clara County Medical Examiner, San Jose, CA
Commonwealth of Virginia Local Medical Examiner, Virginia Beach, VA
Polk County Medical Examiner, Des Moines, IA
District 12 Medical Examiner's Office, Tampa, FL
LifePoint Organ and Tissue Donation Services for South Carolina, Charleston, SC
Association of Organ Procurement Organizations, Vienna, VA
American Association of Tissue Banks, McLean, VA.
The Do's and Don'ts of Working with the Media
Not everything goes right when dealing with the media. Having a clear understanding of how to work effectively with the media from issueing a press release to handling bad press is essential to the smooth operation of a medical examiner's office. Keys to successful media relations such as timeliness, accuracy and throughnes will be discussed. Tips for avoiding such common pitfalls as ignoring questions, not understanding the workings of the press and favoratism will be covered. The importance of quickly handling “bad press” through dissemination of facts, assessing responsiblity and contacting partners will be explained.
Oregon State Police, Milwaukie, OR
The Oregonian Newspaper, Portland, OR.
The Medical Examiner's Office as a Potential Source of a Wide Range of Disorders Needed for Medical Research
The NICHD Brain and Tissue Bank (NICHD BTB) has worked closely with the Office of the Chief Medical Examiner (OCME) in Baltimore since 1991. The project is under the supervision of the IRB of the University of Maryland School of Medicine and the Maryland Department of Health and Mental Hygiene. The role of the NICHD BTB is to inform families of the need of tissue donation for research, obtain consent, recover tissue after the autopsy is completed, store and evaluate the quality of the tissue, and make it available to the international research community. The total number of donors to NICHD Brain and Tissue Bank that were under the supervision of the OCME was 1124. Of these, 714 cases were designated as controls, meaning that 410 had a disorder that affected the brain. The control cases may have had disorders not involving the brain such as cardiac disease, etc. Although the OCME is the sole source of control tissue for researchers supported by the NICHD BTB, there are several disorders that can only be obtained through the cooperation of the OCME because a complete autopsy is required before diagnoses can be assigned. The following disorders fall in this category: Sudden Unexpected Infant Death (SUID), Sudden Infant Death Syndrome (SIDS) and Unexpected Death in Epilepsy (SUDEP). Brain and other tissues have been donated from individuals with approximately 50 disorders by relatives of individuals scheduled for autopsies at the OCME. The disorders represent SIDS (164), chromosomal disorders (25), autism spectrum disorder (24), and epilepsy (23). Additional more rare disorders at the OCME that have filled the needs of researchers are: Angelman syndrome, cerebral palsy, Huntington's disease, neurofibromatosis, Prader-Willi syndrome, Tourette Syndrome, tuberous sclerosis, Williams syndrome, Zellweger's syndrome, etc. Psychiatric disorders also contribute to the case load at medical examiners: schizophrenia, depression, Alzheimer's disease, bipolar disorders, ADHD, and drug abuse. Some of these are not the focus of the NICHD BTB, but are for other brain and tissue banks. These data indicate that the office of medical examiners is not only the only reliable source of control tissue but is also vital to supporting research on many disorders, especially autism, sudden deaths in children, adults with epilepsy. The National Institutes of Health actively supports brain and tissue banks, all of which depend on collaboration with medical examiners offices to advance medical research.
University of Maryland School of Medicine, Baltimore, MD
Office of the Chief Medical Examiner, Baltimore, Baltimore, MD.
Medical Examiner Systems: Medical Reserve Corps Volunteers – Force Multipliers during Mass Fatality Events
This presentation will address a unique, locally available force multiplier during a mass fatality event. During mass fatality events, medical examiner and coroner offices have an immediate, rapid need to increase available staff to assist with phone calls, documenting clothing and personal effects, obtaining x-rays, moving body bags, and assisting the pathologists, dentists and anthropologists with workflow. Prior training and planning allows these offices to have a trained and ready force that has been fingerprinted, has already passed background checks, and has been trained to assist the medical examiner/coroner. This talk will present information on the cooperative and collegial partnership, under the Virginia Department of Health umbrella, between the Office of the Chief Medical Examiner and statewide/local health department Medical Reserve Corps units. MRC volunteers may require additional supervised training in confidentiality, the National Incident Management structure, Psychological First Aid, Responder Readiness, etc. MRC volunteers will need in-house courses to introduce them to the Medical Examiner/coroner system, to teach them how to complete Family Assistance Center forms and handle information resources, collect DNA samples, be custodians of evidence, and to expose them to autopsy procedures. The scope of training considerations should be planned prior to the project's onset. Additional training in autopsy technician skills awareness may be taught using anatomical donors. Funding for training may be included in local health department, MRC or medical examiner/coroner office budgets. The OCME can provide much of the in-house training for little to no additional expense beyond staff time. Creative grant requests, such as will be discussed in this presentation, may provide funding for training. This discussion of the Virginia OCME program will provide an example of how a successful Medical Reserve Corps volunteer training program can be planned out, funded, and managed to provide a reliable force multiplier in the event of a mass fatality.
Virginia Office of the Chief Medical Examiner, Norfolk, VA.
NIST Organization of Scientific Area Committees (OSAC): Input Received and Proposed Plan Development
The development of a quality infrastructure for forensic science was a key component of some of the reforms anticipated in the National Academy of Sciences (NAS) report. In response to the report, the National Institute of Standards and Technology (NIST) and the US Department of Justice signed a bilateral agency Memorandum of Understanding (MOU) in March 2013 which specified the establishment of “Guidance Groups” now termed Scientific Area Committees (SACs). NIST created the Organization of Scientific Area Committees (OSAC) model to promulgate NIST's responsibility to administer and coordinate support for the discipline-specific SACs. In September 2013, NIST issued in the Federal Register a Notice of Inquiry (NOI) to obtain national and international input on the establishment and structure of governance models. Eighty-two submissions were received in response to the NOI. NIST envisions uniform administration of development, promulgation and adoption of standards through the OSAC as well as supporting communication flow between the SACs and the forensic science community. The plan design intends to bring structure, scientific rigor and increased communication among forensic scientists, research scientists, academicians, statisticians, attorneys, managers and quality assurance specialists. On January 29, 2014, NIST briefed the NAME President on the OSAC model and possible affects to the NAME organization. Modifications to the model and current activities will be presented.
NIST, Gaithersburg, MD.
Maintenance of Certification (MOC) for the Forensic Pathologist
The American Board of Pathology (ABP) began issuing time-limited certificates in 2006. New diplomates since that time must participate in the ABP program of Maintenance of Certification (MOC) in order to maintain board certification. MOC consists of 4 parts: I) Professional Standing (medical licensure and scope of practice); II) Lifelong Learning and Self-Assessment (required CME and SAM [Self Assessment Module] credits); III) Cognitive Expertise (a mandatory re-certification exam at the ABP testing center); and IV) Evaluation of Performance in Practice (laboratory accreditation, performance improvement and quality assurance at laboratory level and at individual level, peer attestations, and patient safety). The Part IV requirements have grown since the inception of MOC, with the requirement of the patient safety module mandated by the ABMS. Toward the end of each 10-year MOC cycle, anytime in the 7th through 10th years but before the 10-year certificate expiration date, a re-certification exam is required (MOC part III, Cognitive Expertise). One forensic pathologist sat for and passed the first offering of the FP subspecialty recertification exam in March 2014; at least 8 forensic pathology subspecialty-boarded individuals are currently registered to take the fall 2014 re-certification exam. While 5600 diplomates of the ABP are required to participate in MOC currently, only 298 (5.3%) of those diplomates have a forensic pathology certificate. The forensic pathology practice environment is often much different than that of the hospital pathologist, and the implementation of some MOC requirements potentially more challenging. This presentation from three MOC-participating forensic pathologists (the Chair of the NAME SAM/MOC subcommittee, another member of the committee, and the first forensic pathologist to pass the re-certification exam), will offer a primer on MOC specifically for the forensic pathologist, including strategies for meeting the requirements of all four parts of MOC, and will address misunderstandings and rumors that may persist about MOC requirements and the re-certification exam. The information presented is based on current guidelines published by the ABP as well as information gathered by the presenters from ABP representatives regarding forensic pathology-specific points of inquiry. Of particular import to those diplomates facing their first re-certification exam will be a discussion of the structure and scoring of the exam, options for maintaining primary and subspecialty certificates vs. subspecialty only, and differing viewpoints on the merits of each of those options.
Onondaga County Medical Examiner's Office, Syracuse, NY
Medical University of South Carolina, Charleston, SC
Pima County Office of the Medical Examiner, Tucson, AZ.
The Sudden Death in the Young Registry
*Acknowledgement- SDY Registry Steering Committee: NIH, NHLBI and NINDS; CDC, National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP); Michigan Public Health Institute (MPHI)
DB Consulting Group Inc. for CDC, Chamblee, GA
DB Consulting Group Inc. for CDC, New Orleans, LA
Independent Contractor, Elmhurst, IL.
Synthetic Cannabinoid Drugs as a Cause or Contributory Cause of Death
Synthetic cannabinoid drugs have specific binding at the cannabinoid CB1 receptor, and produce marijuana—like effects including, euphoria, relaxation, tachycardia and hypertension as well as evidence of anxiety, paranoia and panic, not typically associated with marijuana. To date, three deaths associated with synthetic cannabinoids have been reported including a coronary ischemic event, a suicide due to anxiety, and a fatal acute overdose from MAM-2201. We report a case series in which synthetic cannabinoids were cited as a cause or contributory cause of death. Participants were recruited through the NAME list serve. As of May 5th, 2104, 19 cases had been submitted. The cases date from April 2010 to the present, and include 3 females, 16 males, mean/median age 33/29, range 17–55. All cases included had toxicological confirmation of synthetic cannabinoid use. The specific substances detected were AM-2201 (n=7), JWH-122 (n=6), XLR-11 (n=4), JWH-210 (n=4), JWH-018 (n=2), UR-144 (n=1). Most of the subjects had some known drug use history. Only 3 cases also had indicators of THC from botanical marijuana use. Synthetic cannabinoids frequently were found with other drugs including opiates, methadone, MDMA, amphetamines, hydrocodone, but none of the other substances were present in more than 2 cases each. Most of the subjects were found in proximity to packaged synthetic cannabinoid materials, or drug smoking paraphernalia, suggesting that many of these deaths occurred proximate to the time of use, however a caveat is that since the drugs are not routinely detected in routine drug testing procedures (either immunoassay or chromatographic), other cases without the scene information may have been missed. Of the nineteen cases, five were attributed specifically to synthetic cannabinoid toxicity, in the absence of other causes or drugs. Three cases were attributed to mixed drug intoxication, where the other drugs included THC, opiates and amphetamines. An observed seizure was recorded in one case. Falls or jumps from a height were recorded in two cases. In the remaining cases there was also significant natural disease especially obesity, significant coronary artery disease and myocardial infarction. This preliminary case series represents the largest group of cases where synthetic cannabinoids have been determined to be a significant cause or contributory cause of death. The drugs hypertensive effects, behavioral toxicity, ability to trigger seizures, and other unknown toxic mechanisms represent important investigative information in determining cause and manner of death.
NMS Labs, Willow Grove, PA
Denver Office of the Medical Examiner, Denver, CO
Cuyahoga County Medical Examiner, Cleveland, OH
San Francisco Medical Examiner, San Francisco, CA
San Diego County Medical Examiner, San Diego, CA
Onondaga County Medical Examiner, Syracuse, NY
Office of the Chief Medical Examiner, Tulsa, OK
Montgomery County Coroner, Norristown, PA.
NIJ Programs to Support the Forensic Pathology Community: Strategies for Stronger Proposals in a Competitive Environment
There are various types of Federal funding opportunities, and generally speaking, they can be broken down into two types: competitive and non-competitive. Non-competitive funding can come in the form of formula grants or sole-source grants/contracts. Competitive funding is just that: competitive. This workshop will focus on competitive funding opportunities issued by the National Institute of Justice (NIJ) for research or direct service assistance related to forensic pathology and medical examiner/coroner services. This workshop will discuss four programs issued by the NIJ that support the forensic pathology community: Paul Coverdell Forensic Science Improvement Grants Program, Using DNA to Identify the Missing Program, National Missing and Unidentified Persons System (Na-mUs), and Research and Development in Forensic Science for Criminal Justice Purposes Program. The NIJ Program Managers for each of these programs will discuss the specifics of each, to include purpose, eligibility, and emphasis on how to write to the selection criteria. Common mistakes and best practices will be reviewed. Requirements including, but not limited to, the program narrative and budget documents will be discussed. A brief overview of NIJ's current forensic pathology research and development and assistance portfolio will also be provided. The goal of this workshop is give attendees an overview of the current NIJ programs that support the forensic pathology community and to provide attendees with the knowledge and skills to write stronger grant proposals responsive to these programs. Learning Outcomes: 1) Learn about NIJ Programs that support the forensic pathology/medical examiner/coroner community. 2) Learn how to read an NIJ solicitation and what key areas to focus on. 3) Learn how to write a stronger competitive proposal.
National Institute of Justice, Washington, DC.
Who are the Medical Experts - the Medico-Legal Council?
A second medical expert opinion is in Denmark provided by the National Medico-Legal Council (MLC) in court proceedings of criminal and civil cases.
The MLC was established by law more than 100 years ago, and its statutes have remained almost unchanged since then. According to this law, the MLC has to give a written secondary medical evaluation free of charge in court proceedings involving the legal rights of an individual. The medical evaluation is based on statements by other medical doctors having examined the patient or the deceased. Usually, three highly scientifically qualified experts within different medical disciplines are appointed by the chairman of the council to reevaluate the case. Each medical expert gives his or her opinion in writing to the MLC before a final written report based on the opinion of the medical experts is submitted by the chairman of the council to the court. Thus, the court avoids having to call another second medical expert. The voting member of a case may from time to time be called to give testimony and to explain the opinions given by the voting members on a specific case. The second medical expert opinion given by the MLC has a high esteem in Danish courts, and it is very seldom overruled, as it is also unusual for Danish judges to allow the defense attorney to call another medical expert to give testimony in the individual case. A case of death in police custody will illustrate the way the council works and the weight the court puts on the opinion of the council. It is recommended to look at this organization when an objective second opinion from medical experts is needed.
Aarhus University, Aarhus, Denmark
An Enhanced Tissue Recovery Donor Referral Program for Non Hospital Deaths
The ability of Organ and Tissue procurement agencies to meet the demand of those in need is a growing concern. Potential organ recovery cases are easily identified as the death occurs in a hospital. Conversely, tissue/cornea recovery may occur up to 24 hours after death and many of these deaths occur outside the hospital. Benefits of internal organs and corneas recovery are well known, but the importance of tissue recovery needs to be emphasized. Tissue donation may include skin for burns and wound care, bones and tendons for orthopedic surgeries, and pericardium for dental surgeries. Tissue recovery from one body may touch 50 lives or more. In order to increase potential donors Lucas County Coroner's Office, Toledo Ohio and Community tissue services Northwest Ohio Branch tissue bank (CTS NWT) have formed a unique collaboration between the two agencies. Lucas County Coroner's Office performs autopsies for 19 Northwest Ohio Counties. Approximately 1000 autopsies and about 200 external examinations (by four board certified forensic pathologists) are performed annually. The Northwest Ohio branch (CTS NWT) of Community Tissue Services (full service tissue bank headquartered in Dayton Ohio) works with approximately 28 hospitals and healthcare facilities in 18 different counties around Toledo, Ohio area with approximately 250–300 donors recovered annually. Last year (2013) there were a total of 112 referrals sent to tissue bank (CTS NWT) from the Coroner's Office. Consent was obtained for 29 (45%) eligible referrals, of these 10 cases (34%) were actual tissue and cornea donors.
The enhanced donor referral program for non hospital deaths was established to ensure that the tissue bank received timely referral of potential eligible donors. As part of the program, Coroner's investigators automatically send information on the deceased to the tissue bank upon death notification of non hospital Lucas County and contracting counties cases. Prior authorization by the contracting County Coroners allows referral of all out of county cases. Tissue bank would then assess the donor eligibility and approach the Coroner's office for pre autopsy permission for recovery to maximize donation and reduce contamination. Pre autopsy tissue recovery has not been found to interfere with determining cause and manner of death, provided proper documentation is done and both agencies work closely together.
There has already been a marked increase in the number of referrals to tissue bank (CTS NWT) since the programs recent inception.
Lucas County Coroner's Office, Toledo, OH
Community Tissue Services, Northwest Ohio Branch, Toledo, OH.
National Neurobiobank Tissue Sharing Consortium: Networking with Medical Examiners
To expedite research on brain disorders, the National Institutes of Health is coordinating a resource for sharing post-mortem brain tissue that is donated for research. Under a NIH NeuroBioBank initiative, five brain banks began collaborating in 2013 under a federated archived brain and tissue-sharing network to support the neuroscience community. The new brain banks are located at the Mount Sinai School of Medicine, New York City; Harvard University in Cambridge, Mass., the University of Miami Miller School of Medicine; Sepulveda Research Corporation, Los Angeles; and the University of Pittsburgh. These brain and tissue repositories accept brain donations, store the tissue, and distribute it to qualified researchers seeking to understand the causes of and identify treatments and cures for brain disorders, such as schizophrenia, multiple sclerosis, depression, epilepsy, Down syndrome and autism. Although the project seeks brain tissue from people with brain disorders and non-affected individuals of any age who register before death as potential donors, next-of-kin can also give permission for donation of tissue from children with or without brain disorders and those affected adults who have not registered before death. Post-mortem consents for brain and tissue donation for research often occur in a medical examiner jurisdiction. Medical examiners and coroners play a vital role in organ and tissue procurements for transplantation. Coroners and medical examiners may allow donation of brain for research to occur and still fulfill their medicolegal responsibilities, but the practical guidelines and working relationships need to be better established. The balancing of the interests and responsibilities of the medical examiner can be met while supporting the activities of the brain donation programs, through the NeuroBioBanks sharing information on the results of the neuropathology examination and providing detailed written documentation of gross pathology with photographs of brain, serology and supplemental brain toxicology tests. Donated specimens are stored in a biorepository that tracks chain-of-custody for specimens that are cryopreserved or placed in formalin. Tracking chain-of-custody is important not only for the research projects that received brain specimens, but also ensures that these tissues are retained and are available if the medical examiner or coroner requires their return for presence of disease, or cause or manner of death determination.
University of Miami, Miami, FL
McLean Hospital, Boston, MA
VA Greater Los Angeles Healthcare System, Los Angeles, CA
Mount Sinai School of Medicine, New York City, NY
University of Pittsburgh, Pittsburgh, PA.
An Investigative Tool for Detecting Elder Abuse
Elder abuse has been estimated to affect one in ten individuals sixty years of age and older and has been found to significantly increase the risk of mortality. However, no clear data exists on the number of deaths that result from elder abuse or neglect. The potential contribution of abuse and neglect to the death of an elder is rarely investigated, as natural deaths are expected with advancing age. Elder individuals are often reliant on others for care and activities of daily living making them a population vulnerable to abuse and neglect. Although the deaths of other vulnerable populations, including children and those in the care of law enforcement, are routinely investigated, no protocols for elder death investigation have been implemented. In this presentation, we propose using an investigative tool to assess the elder decedent and the decedent's residence for indicators of abuse or neglect. Information gathered assists in differentiating between self-neglect and caretaker neglect. Observations of the decedent include: evidence of injuries, personal hygiene, malnutrition and/or dehydration, decubitus ulcers, evidence of restraint, vaginal or anal bleeding. In addition, determining whether reports filed with Adult Protective Services suggest a history of neglect or abuse. A proposed method to differentiate between self-neglect and caretaker neglect includes an assessment of the level of dependence on others for activities of daily living and the level of involvement of the caretaker. Medicolegal death investigators should also take note of the decedents living conditions and caregivers, including whether the decedent was subject to forced isolation; lack of food, water or utilities; soiled clothing and/or bedding; filthy or unsafe living conditions; and inappropriate administration of medications. With proper training, Medical Examiners can easily implement these protocols into practice. Such information is extremely valuable for determining whether further investigation and examination of the decedent is warranted.
Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI.
Ketamine-Induced Nephropathy: A Case Report and Review of Current Abuse-Related Pathology
Ketamine is employed clinically as a dissociative anesthetic. Ketamine abuse is a growing problem in East Asian countries. This presentation reports a case of death due to renal failure from chronic ketamine abuse. The decedent was a chronic ketamine abuser who was found dead at home. Significant autopsy findings included shrunken, scarred kidneys and bilateral hydronephrosis. Microscopically, the kidneys demonstrated features of end-stage renal disease with a component of chronic interstitial nephritis. The bladder examination was limited but had features consistent with long term ketamine abuse. Toxicology revealed a low level of Ketamine and vitreous electrolyte testing confirmed renal failure. The certification of this death, a review of ketamine-related pathology and the growing public health problem of ketamine abuse in East Asia are also reviewed.
New York City Office of Chief Medical Examiner, New York, NY.
The Utility of Touch DNA Evidence Collection from Decedents at the Harris County Institute of Forensic Sciences
Cells containing DNA are transferred from skin to skin or from skin to objects during contact. When an assailant touches a victim, the victim's clothing, or objects used to bind a victim, cells containing the assailant's DNA are transferred, referred to as touch DNA. It is the experience of the Harris County Institute of Forensic Sciences (HCIFS) that when properly collected, touch DNA can be detected at an unexpectedly high rate. The recovered DNA can be used to identify individuals involved in the crime and/or link crimes committed by the same person(s). Proper collection techniques and the successes over the years will be illustrated in this presentation. Over the last decade, the HCIFS has developed policies and procedures to optimize the collection of foreign DNA from decedents. We employ a team of twelve qualified DNA analysts who are on call to attend death scenes to collect trace amounts of DNA from decedents. Initially, the team was focused on the collection of traditional trace materials such as hairs and fibers found on decedents. As DNA technology improved, the team shifted to the collection of DNA. We now find foreign DNA in up to 80% of the cases that are tested and this DNA is frequently linked to a suspect or an individual of interest in the case. The results have been tracked over several years and the presence of foreign alleles has increased dramatically over time, assisting homicide investigators in identifying a potential suspect in over 50 homicide cases. During the transportation of the decedent from the crime scene to the morgue, trace amounts of DNA, as well as visual indications of stains, may be obscured by blood and other body fluids. When the decedent is bound, has been dumped or moved, or involved in a close contact altercation, an HCIFS Trace DNA Evidence Collection Team Analyst will be dispatched along with the medicolegal death investigator to collect DNA and other trace evidence from the decedent at the crime scene. The analyst will collect samples directly from the body or other objects associated with the body (clothing, bindings, ligatures, weapons remaining in the body) and release this evidence to the law enforcement agency assigned to the investigation.
Harris County Institute of Forensic Sciences, Houston, TX.
NAME Trivia 2014
This brief presentation is a continuation of a traditional annual presentation in which trivia is presented about NAME, its activities, and its members. It is meant to be educational but also light-hearted, offering a look at NAME which is not usually addressed in other presentations or forums at NAME meetings.
Fulton County, GA, Emory University School of Medicine, Atlanta, GA.
Antemortem, Perimortem, or Postmortem Change? A Case of Fascinating Fossorial Forensics
A case in which the cause of death was clear was referred for consideration of additional injuries. Possibilities included antemortem torture, perimortem mutilation, and postmortem destruction of portions of the body. Discussion of this case will include analysis of injury pattern, description of potential mechanisms, and appropriate conclusions. The role of the consulting forensic pathologist will be discussed, with attention to the appropriateness of a Wisconsin-based consultant for this particular case.
Milwaukee County Medical Examiner's Office, Milwaukee, WI.
Fatal Religion Based Child Abuse in Oregon
Several religious denominations reject medical treatment in favor of prayer, the most well- known being the Christian Scientists. There are many other smaller religious organizations throughout the USA, some of which have cult-like belief in the power of prayer for healing. The Followers of Christ and Church of the Firstborn are such organizations in Oregon. The Followers are concentrated in Clackamas County, Oregon near Portland. They are a small, closed community governed by a board. They treat illness by anointing with oil and community prayer. Up until 2011, Oregon religious shield law allowed prayer as treatment for illnesses in children to the exclusion of traditional medicine. The Oregon State Medical Examiner's Office and Clackamas County Medical Examiner's Office investigated a number of preventable natural deaths in children belonging to the Followers of Christ church. Numerous Followers were routinely present at death scenes and increased in number as the severity of illness increased and death approached. No contact with emergency personnel or traditional medicine was considered. The number of deaths and the suffering of these children resulted in conversations between medical examiners, law enforcement, district attorneys and eventually the public as these deaths were reported in the news media. The consensus was that parents had a duty to provide medical care for their children beyond prayer regardless of the choices they made for themselves. In Oregon, medical examiners, district attorneys and law enforcement were joined by a national organization, C.H.I.L.D. (Children's Health is a Legal Duty), to promote the repeal of Oregon's religious shield law. After two attempts (first in 1999), they were successful in 2011. Oregon is now one of only six states without some form of religious shield law. The difficulties in prosecuting those failing to seek medical care for their children will be discussed by the prosecutor in four recent Oregon cases. Finally, the panel will discuss the steps taken to change the statute in Oregon, which required two law changes and years of effort from C.H.I.L.D., medical examiners, prosecutors, law enforcement, news media and legislators.
Oregon State Medical Examiner's Office, Clackamas, OR
Clackamas County District Attorneys Office, Oregon City, OR
Childrens Health is a Legal Duty (C.H.I.L.D.), Lexington, KY
Oregon State Senate, Salem, OR.
Extension of Perimesencephalic Nonaneurysmal Subarachoid Haemorrhage: A Cause of Nontraumatic Basal Subarachnoid Haemorrhage
Berry anuerysms are the most common cause of acute nontraumatic subarachnoid haemorrhage causing sudden death. In approximately 10% of cases no aneurysm is identified. It is often assumed in such cases that an aneurysm has been missed or destroyed during the process. Radiologically about 10% of subarachnoid haemorrhge is said to fall into the relatively benign category of perimesencephalic nonaneurysmal subarachnoid haemorrhage (PNSH) (1). The cause of PNSH is unknown, in part because it is a relatively benign condition in which few patients die and come to autopsy. However, based on radiological studies it is hypothesized that the source of haemorrhage in these cases may be venous. We present three cases of basal subarachnoid haemorrhage in which no aneurysms were identified but that we believe represent extension of PNSH into fatal basal subarachnoid hemorrhage. In one case the source of haemorrhage was demonstrated to be a large cerebellar vein in the pineal region. Focal acute perivenous inflammation was identified and there were hemosiderin macrophages suggestive of earlier episodes of bleeding. In the second case hemorrhage appeared to be associated with a cluster of arterial and venous vessels in the region of the pineal gland, suggesting an arteriovenous malformation (AVM). In the final case the source of subarachnoid haemorrhage was not identified, but the concentration of blood in the basal cisterns, the lack of intraventricular hemorrhage in the fourth ventricle despite proximity to the major concentration of bleeding, and the relatively prolonged clinical course (24 hours) strongly suggest extension of PNSH. In summary, we have presented three cases that are consistent with extension of PNSH into fatal basal subarachnoid hemorrhage. Furthermore, we believe that one of our cases is the first pathological confirmation of a venous source of PNSH, which has been hypothesized on radiological grounds only. Forensic pathologists should be aware or this entitiy when they encounter nontraumatic basal subarachniod hemorrhage in which they fail to indentify a berry aneurysm.
1) van Gijn J, Kerr RS, Rinkel JE. Subarachnoid Haemorrhage. Lancet. 2007 Jan 27; 369(9558):306-18.
National Forensic Pathology Service, Auckland, New Zealand.
Propofol Related Infusion Syndrome (PRIS) – a Cause for Sudden Unexplained Deterioration on the ICU
We present three young head injury patients who were admitted to specialist neurological intensive care for stabilisation and management. The first patient was a 23 year old female who was admitted to the unit following a road traffic collision after being struck by a motorcycle whilst walking along the pavement. The second was a 19 year old male who was admitted following blunt force trauma to the head and face induced by kicking. The third patient was a 23 year old male who had been admitted from a neighbouring hospital having been found with a head injury caused by kicking and punching to the head, followed by head impact with the ground. As part of the care regime, all three were prescribed and administered a propofol infusion. Propofol is pre-prepared by the manufacturer and sealed in vials, being administered by continuous infusion often by an electronic volumetric pump. The solution is available as a 1 or 2% solution and the higher dose preparation was used on the units where these patients were managed. All three patients died after apparently initially stabilising from the head trauma, following development of refractory broad complex cardiac dysrhythmias, worsening metabolic acidosis, high creatinine kinase indicating rhabdomyolysis, and hyperkalaemia. Propofol (2,6-diisopropylphenol) is a common sedating and hypnotic drug employed on ICUs. The drug has shown neuro-protective and anti-epileptic effects, therefore being useful in the management of patients with acute intracranial pathology. Common side effects which often limit its use include profound hypotension due to cardiac depression and vasodilation. Other side effects including hypertriglyceridaemia have been reported but these effects are often dose- and time-dependent. A rare complication is Propofol-Related Infusion Syndrome (PRIS) first described in 1992 initially in children and those with head injury. The complications of this syndrome which carry a very high mortality include severe metabolic acidosis, rhabdomyolysis, acute kidney injury, hyperkalaemia, lipaemia, hepatomegaly and cardiovascular collapse. The syndrome is thought to occur when high dose propofol infusion is administered over a prolonged period of time, but these patients received doses within the recognised maximum infusion rate of 5 milligrams per kilogram bodyweight per hour. PRIS is almost certainly under recognised and therefore it is important to actively consider this diagnosis in forensic practice in any head-injured patient with a history of rapid unexplained deterioration on the ICU.
The Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, United Kingdom (Great Britain)
North West Group Forensic Practice, Manchester, United Kingdom (Great Britain)
Salford Royal Hospital NHS Foundation Trust, Manchester, United Kingdom (Great Britain).
Suicide by Hypothermia: A Report of Two Cases and Retrospective Review, 1991–April 2014
Hypothermia deaths are frequently accidental and associated with impairment by alcohol, injuries or natural disease. Hypothermia as a method of suicide is unusual, with only rare case reports in the literature. In the early months of 2014, during one of the coldest Minnesota winters on record (ninth coldest since 1873), the Hennepin County Medical Examiner's office (HCME) investigated and certified two cases of suicide by hypothermia. Both individuals were young (29 and 46 years old) white females with histories of depression and making suicidal statements that they wanted to wander out in the cold, lay down, and “freeze to death” in specific locations. Both were found in outdoor scenic locations very close to their residences. Neither exhibited the paradoxical undressing that is frequently seen with hypothermia deaths; both were appropriately dressed for the cold with multiple layers. Autopsies showed minor blunt force injuries of the extremities with no significant life-threatening injury or disease. Wischnewski's gastric ulcers were seen in both cases; vitreous glucose was 37 mg/dL in one case (vitreous not available in the other). Blood toxicology tests were remarkable for alcohol (0.182 g/dL) combined with zolpidem (450 ng/mL) in one case and elevated levels of fluoxetine and metabolite (3900 and 2400 ng/mL) in the other. The deaths were certified as “hypothermia complicated by alcohol and zolpidem toxicity” and “hypothermia complicating acute fluoxetine toxicity,” respectively; depression was a contributing factor. Manners of death were certified as suicide. A search of all cases investigated by HCME from 1991-April 2014 resulted in 146 cases in which “hypothermia” or “environmental cold exposure” was listed as a cause of death, contributing condition, or mechanism of injury. In these cases the manner of death was certified as follows: 116 accident (79.4%), 15 undetermined (10.3%), 8 suicide (5.5%), 6 natural (4.1%), and 1 homicide (0.7%). Of the 8 suicide cases: half were female and half were male, most were young with only one above 50 years of age, 4 were associated with drug toxicities, 5 were associated with additional self-inflicted injuries (blunt force, sharp force, and gunshot wounds), and none of them exhibited paradoxical undressing. It is important for medicolegal death investigating professionals to recognize that, while rare, hypothermia deaths may represent intentional injury and suicide as a manner of death should be considered in all cases. This report and review highlights the rarity of these cases and some of their salient features.
Hennepin County Medical Examiner's Office, Minneapolis, MN.
Establishing a Multidisciplinary Network for the Workup of Sudden Cardiac Death
Jesse E. Edwards Registry of Cardiovascular Disease, Saint Paul, MN
GeneDX, Gaithersburg, MD
Genetic Arrythmia Center at the Minneapolis Heart Institute Foundation, Minneapolis, MN
Hennepin County Medical Examiner's Office, Minneapolis, MN.
Fatal Entrapment of the Basilar Artery in a Longitudinal Fracture of the Clivus due to Head Injury: A Case Report and Review of the Literature
Death from Vertebrobasilar Artery trauma is most commonly encountered in the setting of Traumatic Basal Subarachnoid Hemorrhage that develops in intoxicated individuals who receive a blow to either the jaw or upper neck which causes rotation of the head with hyperextension of the neck, such that tearing of the ipsilateral vertebral artery with the resultant basal subarachnoid hemorrhage occurs. Cases of infarction of the posterior cerebral artery circulation as a result of entrapment of the basilar artery in a fracture of the clivus have been reported in the clinical medical literature but to date, no case of entrapment of the basilar artery in a fracture of the clivus has been reported in the forensic pathology literature. We present a case of an elderly alcoholoic woman who was witnessed to fall down three stairs and hit her head. She was comatose at the scene (GCS 3) but exhibited some transient improvement on arrival at the ER. Her admission blood alcohol was 198 mg/100 ml. CT and MR scans of the brain with angiography revealed: a) Non-visualisation of the mid basilar segment consistent with entrapment by the fractured clivus; b) Acute pontine infarcts in he left PICA territory; c) Possible dissection of the left vertebral artery beyond C2 with thrombosis of the left intracranial vertebral artery and PICA; d) Areas suspicious of intracranial dissection of both vertebral arteries; and e) Subtle fracture of the C5 spinous proceses. Post mortem examination revealed a large subgaleal bruise of the right side of the frontal scalp and a hemorrhagic vertical fracture along the clivus with entrapment of the mid segment of the basilar artery that correlated with the radiological finding. There was a transverse anterior fracture of the body of the C5 vertebra that did not involve the spinal canal or cervical spinal cord. Examination of serial sections of the decalcified, excised cervical spine did not reveal any evidence of dissection of the extra-cranial vertebral arteries. Neuropathological examination of the formalin-fixed brain revealed that the cerebellum exhibited softening in the left PICA territory. The brain stem exhibited a triangular shaped infarct of the midline and paramedian vascular territories of the upper and mid pons. Longitudinal clival fractures associated with entrapment of the vertebrobasilar arteries is unusual. Occlusion of the vertebro-basilar arteries can occur via physical pinching, thrombosis or dissection but other deaths have been the result of direct brainstem trauma or systemic complications.
The Ottawa Hospital General Campus, Ottawa, Canada
The Ottawa Hospital, Ottawa, Canada.
Fibromyalgia: The Nature of its Involvement in Death
Fibromyalgia is a relatively new disease with its clinical diagnosis arising in 1980. The American College of Rheumatology provided classification criteria a decade later and its current incidence in the general population in the US is estimated to be about 2–5%. We introduce a retrospective study of decedents that came to our office with a medical history of Fibromyalgia. We reviewed the demographics, medical history, cause and manner of death, toxicology, co-morbidities, and autopsy findings of one hundred cases and are going to present this data with comparison and contrast to current clinical studies.
Wayne County Medical Examiners Office/ University of Michigan, Detroit, MI
William Beaumont Hospital, Royal Oak, MI.
Draft Best Practices Guide for Medical Examiner/Coroner Involvement with the National Violent Death Reporting System
In September, 2013, NAME received a contract from the CDC to develop a draft best practices guide concerning medical examiner/coroner involvement with the National Violent Death Reporting System (NVDRS) which at the time of the contract, had state-based violent death reporting systems in 18 states. In general, the NVDRS collects data from medical examiner/coroner offices for cases involving homicide, suicide, and unintentional firearms deaths or firearms deaths of undetermined manner. NAME leadership assigned the project to its ad hoc data committee. The goal was to have a draft guide prepared for presentation at the Portland NAME meeting and provision to the CDC by the end of September 2014. During the past year, the committee reviewed numerous reports about the NVDRS system and also collected information and thoughts from forensic pathologist in NVDRS states as well as NVDRS principal investigators and program managers in those states. Multiple emails were exchanged during the year among committee members to review data as it accrued. At the time this abstract was prepared, the draft best practices guide was planned to contain recommended best practices focused on the following areas: 1) medical examiner and coroner participation and data provision; 2) Data issues such as data items and format; 3) Funding and Support; 4) Communication and Cooperation; 5) Within-State Program Management; and 6) NVDRS Policy and Procedure. This presentation will highlight the recommendations which are most directly of interest to medical examiners and coroners. Members of the NAME ad hoc data committee include Christopher Boden, Steve Clark, Tracey Corey, Karen Gunson, Kathryn Haden-Pinneri, Randy Hanzlick, Joseph Prahlow, Erin Presnell, and Linda Szymanski.
Fulton County, GA and Emory University School of Medicine, Atlanta, GA.
Using Postmortem Drug Levels as a Tool in Distinguishing between Non-Accidental and Accidental Fatal Drug Ingestions
Prescription drug abuse has risen to epidemic proportions in the United States. This shift has caused an increase in both the number of accidental and non-accidental drug-related deaths. The distinction between an accidental and suicidal overdose has always been a challenge in America's medicolegal death certification system. In addition to the standard scene investigation, medical history, and past psychological history, the toxicology report has become one the most important tools in distinguishing a non-intentional overdose from an intentional overdose. This retrospective study looks at the postmortem drug concentrations as an additional tool to help in the decision making process between a suicide and an accidental drug overdose. A 4 year (2009–2012) retrospective review of drug concentrations in suicides, accidental overdoses, and undetermined deaths from the Marion County Coroner's Office in Indianapolis was compiled and compared to standard therapeutic drug ranges. For all suicide cases, the top five most frequent drugs/alcohol identified were hydrocodone, ethanol, alprazolam, amitriptyline/nortriptyline, and acetaminophen. For all accident cases, the top five most frequent drugs/alcohol identified were heroin/morphine/associated metabolites, ethanol, alprazolam, hydrocodone, and cocaine/metabolites. Suicides showed statistically significant higher drug concentration(s) when compared to accidental drug overdoses. The average number of times that a drug was elevated over the upper limit of its therapeutic range in suicides was just under 9 times. In contrast, the average in accidental overdoses is just under 2.5 times. The average number of total drugs positive in a suicide cases was 4.06 compared to 2.45 drugs seen with accidents. The percentage of cases where ethanol was identified in suicides was 27.54% which is very similar to accidents at 25.91%. Assigning a definitive manner of death (accident, suicide, and undetermined) in fatal drug ingestion cases where subjective variables play a significant role is challenging and the possible use of a stratification system (i.e. Undetermined, favor accident) may allow for more accurate reporting of drug related deaths.
Marion County Coroner's Office, Indianapolis, IN
Indiana University-Purdue University-Indianapolis (IUPUI), Indianapolis, IN.
Characterization of Diphenhydramine-Related Overdose Deaths
Diphenhydramine has been identified in fatal drug poisonings, generally when combined with other drugs or as a single intoxicant more commonly in suicides. Previous reports of DPH involvement in drug overdose deaths are limited by small sample sizes and a focus on suicides. The Forensic Drug Database (FDD) was developed to capture comprehensive data from WV drug-induced deaths. A project subsequently funded by the WV Injury Control Research Center and CDC added findings from Maine, Vermont and New Hampshire to the FDD. The database currently contains drug-induced death data from January 2005 through most of 2011. The present study compared characteristics of unintentional DPH-induced deaths to those deaths not involving DPH. Of the 4,709 drug-induced deaths in the FDD, 3884 (82.5%) were unintentional. Of 276 total DPH-induced deaths, 181 (65.6%) were unintentional. These 181 DPH deaths were compared to the 3,703 unintentional non-DPH deaths. There were no statistically significant differences (p>0.05) between the DPH and non-DPH deaths for age and BMI distributions, or in the proportions of cases with co-intoxicant benzodiazepines (~42% of deaths overall) or opioids present (~88% of deaths overall). In linear regression analyses, DPH presence was not significantly associated with fentanyl, hydrocodone, methadone, or oxycodone concentrations, with and without adjustment for the presence of alcohol, benzodiazepines, TCAs, and SSRIs and age, sex and BMI covariates, although individual sample sizes were small. Several characteristics differed significantly (p<0.005 for each) between DPH and non-DPH deaths. Decedents with DPH present were more likely to be female (57.5% females in DPH deaths vs. 31.5% females in non-DPH deaths). The number of co-intoxicants present differed significantly between groups (55.8% of DPH deaths had > 3 other co-intoxicants present vs. 20.1% of non-DPH deaths). Median diphenhydramine concentrations decreased slightly from 0.25 mcg/ml with 1 other co-intoxicant present to 0.16 mcg/ ml with 4+ other co-intoxicants identified. Alcohol was significantly less likely to be present in DPH compared to non-DPH deaths (13.3% vs. 22.5%), and antidepressants (TCAs and SSRIs) were significantly more likely to be present in DPH compared to non-DPH deaths (26.5% vs. 11.2%, respectively). Methadone was the most frequently identified drug in DPH overdose deaths when only 1 or 2 other co-intoxicants were present; diazepam and alprazolam were most frequently identified drugs in DPH deaths with > 3 other co-intoxicants. Identifying factors that characterize DPH-related deaths is important when assessing the possible role of DPH in unintentional deaths.
West Virginia University, Morgantown, WV
University of Maine, Orono, ME
West Virginia University School of Public Health, Morgantown, WV
West Virginia Office of the Chief Medical Examiner, Charleston, WV
Maine Office of the Chief Medical Examiner, Augusta, ME
New Hampshire Office of the Chief Medical Examiner, Concord, NH
Vermont Office of the Chief Medical Examiner, Burlington, VT
West Virginia University School of Pharmacy, Morgantown, WV.
Fatal NBOMe Intoxication: Toxidrome, Autopsy Findings, Detection and Legal Challenges
NBOMe, a “2C” designer drug is known to be a potent 5HT2A agonist. Originally synthesized in 2003 as a research agent, this drug has recently appeared as a drug of abuse, first in Europe, then in the United States. It is typically sold as a liquid or on blotter papers, the latter form frequently represented by dealers as LSD. Two fatal cases are reported; a 17-year-old female who had a seven day hospitalization following her acute presentation and a 19-year-old male who died at the scene of ingestion of the drug. Toxidromes in both cases showed similarites to one another as well as to the small number of cases of both fatal and non-fatal NBOMe intoxication reported in the literature. The initial history of “LSD” ingestion led to fruitless toxicological searches for this agent in both currently reported cases, but ultimately directed analysis revealed the true nature of the intoxications. Both cases underwent autopsies by forensic pathologists who reached differing conclusions as to the cause and manner of death in their respective cases. Autopsy findings in both are presented as well as a discussion of the ultimate detection of the agent in question in postmortem blood. In the case of the 17-year-old female, no arrests or other legal action has ensued. In the case of the 19-year-old male, one of his companions the night of the intoxication was arrested and charged with second degree murder by strangulation. The author, who performed the autopsy of the female in his own jurisdiction, was a defense expert in another jurisdiction in the trial of the youth charged in the death of the male decedent. Prosecutors raised a number of objections to testimony regarding NBOMe that shall be reviewed in this presentation. Forensic pathologists must remain vigilant for the emergence of an increasingly wide variety of synthetic intoxicants, many available legally, in their jurisdictions. A thorough investigation of the circumstances and accoutrements of the intoxication, detailed description of the symptoms observed in the decedent and working knowledge of how such agents may cause death ensure accuracy in death certification and may have profound impact on the adjudication of cases involving this burgeoning public health problem.
Office of Chief Medical Examiner, Concord, NH.
Comparison of Drug/Metabolite Stability in Specimens Transported in Ambient Temperature versus on Dry Ice
Many coroner and medical examiner offices do not have on-site toxicology laboratories and must transport postmortem specimens by some type of courier system to their lab of choice for testing. Various modes of transportation are used and may include a dedicated courier service traveling by car, overnight transportation via a commercial transport such as FedEx or UPS, or through the US Postal Service. The temperature and humidity may fluctuate widely during transport due to these variable modes of transportation and regional temperature differences, which may lead to degradation of drugs/metabolites during transport. Specimens may be shipped to the laboratory on dry ice to minimize potential analyte instability; however, this may be cost prohibitive for many offices. We evaluated whether specimen transport conditions significantly affected drug/metabolite stability in postmortem femoral blood. Two femoral blood samples were simultaneously collected from the inguinal region of 112 decedents. One sample was immediately refrigerated at 4 degrees C until transport and then packaged in a Styrofoam shipping container and sent to the laboratory at ambient temperature. The other femoral blood specimen was immediately frozen and kept at −20 degrees C. This specimen was packaged like the first specimen except dry ice was included to maintain a frozen state until delivery to the laboratory. Both specimens were transported using an overnight commercial carrier. Temperatures were not regulated in the storage area of the carrier planes and could range from near freezing to over 32 degrees C during the transport. Upon arrival to the laboratory, the specimens were analyzed for drugs/metabolites included in a comprehensive test panel according to laboratory protocol. The frozen specimen delivered on dry ice was thawed prior to testing. Statistical differences between drug/metabolite concentrations in the two specimens were evaluated using a paired T –test (p<0.05). Seventy-eight different drugs and/or their metabolites were detected. The most commonly detected analytes were alprazolam, 7-aminoclonazepam, morphine, oxycodone, ethanol, diphenhydramine, citalopram, delta-9-tetrahydrocannabinol, and methadone. Significant differences were observed in 3 analytes; delta-9-carboxy-THC, 2-thylidene-1,5-dimethyl-3,3-diphenylpyrrolidine (methadone metabolite), and amphetamine concentrations were significantly lower when compared to the specimen shipped in ambient temperature. This suggests that multiple freeze-thaw cycles may significantly affect the stability of certain analytes; however, the majority of analytes were unaffected by differences in shipping conditions in overnight transport.
Wake Forest School of Medicine, Winston-Salem, NC
Alere, Richmond, VA
Iowa Office of the State Medical Examiner, Ankeny, IA
AIT Laboratories, Indianapolis, IN.
Feedback to the Field: Incorporating Postmortem Computed Tomography in the Evaluation of Trauma Care
Armed Forces Medical Examiner System, Dover AFB, DE.
Medical Examiner Collection of Comprehensive, Objective Medical Evidence for Conducted Electrical Weapons and Their Temporal Relationship to Sudden Arrest
St. Louis University, St. Louis, MO
Private Consultant in Cardiac Pathology and Toxicology, Berkeley, CA
Consultant in Forensic Pathology, Suffolk, NY
University of Minnesota, Minneapolis, MN
LAAW International LLC, Scottsdale, AZ.
Silent but Deadly: HazMat Implications of Lethal off Gassing in a Suicidal Aluminum Phosphide Poisoning
The presentation illustrates the importance of early cooperation between state, local, and private entities when managing a case of chemical suicide. Aluminum phosphide is a highly toxic, low cost rodenticide used in other countries to protect food supplies. When exposed to water, it releases phosphine gas that effectively kills pests but leaves food edible after the phosphine gas dissipates. It is readily available overseas, usually in tablet form, and can easily be brought into the U.S. where is is not widely sold. Since the early 1980's, it has been frequently used as a suicidal agent in the Middle East and Asia. A female foreign national admitted to intentionally ingesting tablets of aluminum phosphide when she was found vomiting in the bathroom by her adult son who called 911. EMS responded and transported her to a local hospital Emergency Department where she was initially treated with IVs, cardiac monitoring, NG/ET intubation and mechanical ventilation in a critical care treatment room. After an hour, ED staff complained of burning eyes and skin so the patient was moved to a negative air flow isolation room and local HazMat was called. HazMat responded with phosphine monitors, recommended hospital staff don Level 3 PPE and erected a secure, decontamination tent in the EMS parking area outside the ED. The patient was moved into the tent with treatment equipment, but expired an hour later. The medical examiner was notified and decided an external examination without autopsy would be conducted in the decon tent when it was deemed safe. The NG tube was removed per hospital protocol, but the ET tube was not, and the body was left undisturbed. Two hours after death, the phosphine level in the tent was 112 ppm and two hours after that it was 90 ppm, exceeding the “immediately dangerous to life or health” level of 50 ppm. Medical examiner staff examined the body and drew toxicology specimens wearing respiratory protection (PAPRs) 26 hours after death when the monitored tent phosphine level was 0. A funeral director in India was consulted to determine a safe method of disposition. The body was transported in a Bio-Seal bag and cremated at a local crematory with HazMat monitoring the crematory emissions throughout the process, which remained 0. In conclusion, EMS, hospitals, HazMat teams, medical examiners and funeral directors need a cooperative plan for safely managing chemical suicides as they become more frequent.
1. Virginia Commonwealth University, Richmond, VA.