National Association of Medical Examiners Position Paper: Recommendations for the Documentation and Certification of Disaster-Related Deaths.

ABSTRACT: Collecting and reporting accurate disaster mortality data are critical to informing disaster response and recovery efforts. The National Association of Medical Examiners convened an ad hoc committee to provide recommendations for the documentation and certification of disaster-related deaths. This article provides definitions for disasters and direct, indirect, and partially attributable disaster-related deaths; discusses jurisdiction for disaster-related deaths; offers recommendations for medical examiners/coroners (ME/Cs) for indicating the involvement of the disaster on the death certificate; discusses the role of the ME/C and non-ME/C in documenting and certifying disaster-related deaths; identifies existing systems for helping to identify the role of disaster on the death certificate; and describes disaster-related deaths that may require amendments of death certificates. The recommendations provided in this article seek to increase ME/C's understanding of disaster-related deaths and promote uniformity in how to document these deaths on the death certificate.

Postmortem THC in decedents following legalization of recreational cannabis in Clark County, Nevada.

Marijuana is the most prevalent illicit substance used globally. With increasing US legalizing recreational marijuana, more evidence is vital to minimize potential health risks. This study was conducted to test several hypotheses regarding postmortem THC/COOH-THC in decedents before and after legalization of recreational marijuana in Nevada. We also compared presence of THC/COOH-THC in decedents with respect to manner of death as recorded by the Clark County Office of the Coroner/Medical Examiner. THC/COOH-THC concentrations for years 2015-2016 (pre-legalization) and 2017-2019 (post-legalization) were compared through an independent samples t-test and chi-square tests. A binary logistic regression was used to compare the presence of THC/COOH-THC with covariates: age, gender, race, and manner of death. The average concentration of THC/COOH-THC detected per decedent did not significantly differ before and after recreational legalization, whereas the proportion of decedents testing positive for THC showed a small but significant increase following legalization although no significant change in COOH-THC was detected. The likelihood of testing positive for THC/COOH-THC decreased as age increased. Sex, race, and manner of death were all associated with the relative risk of presence of THC/COOH-THC in toxicology reports. An increase in proportion of users but not in concentration of THC/COOH-THC was observed after legalization. The results are generally consistent with national reports and suggest toxicology data from decedents is a valuable method for surveying marijuana use by the general public. The early adoption of recreational marijuana by neighboring states may have precluded any major changes in use following legalization in Nevada.

The Phenomenon of the Urban Mummy.

The environmental mummification of a body in an urban setting is an unusual event. Florida is known for its high temperatures and humidity, which typically result in the rapid putrefaction of bodies. However, under certain circumstances, Florida's climate provides an environment suitable for mummification, typically in isolated areas. We previously reported a case of a homicide/suicide in a residential neighborhood in which the mummified remains were undetected for several years. We have subsequently encountered two additional cases in which mummified bodies were discovered in urban settings. Presented in the historical context of the environmental conditions and postmortem processes involved in mummification, these cases illustrate the particular constellation of human behaviors and scenarios, as well as environmental conditions, which must coincide for this phenomenon to occur and highlight the necessity of the multidisciplinary approach to the medicolegal investigation of such deaths and the determination of the cause and manner of death.

Fatalities due to indigenous and exotic species in Florida.

Florida's climate is suitable for many potentially hazardous animals, including both indigenous and exotic species, which are frequently kept as in zoos or as pets. This has resulted in many unforeseen fatal encounters between animals and the ever expanding human population. While the literature and knowledge pool for more common types of deaths referred to medical examiner/coroner's offices is abundant, the appreciation of wildlife and exotic pet-related deaths is far less widespread. We report seven animal attack-related deaths that occurred in Florida. The inflicted injuries included blunt and sharp force injuries, asphyxia, drowning, and envenomation. The underlying cause of death, however, was always a result of the human/animal interaction and in many cases related to human error and failure to appreciate the potentially dangerous behavior of nondomesticated species. These cases illustrate the varied circumstances and pathophysiologies associated with deaths due to indigenous and exotic species and the importance of the multidisciplinary approach in the medicolegal investigation of these cases.

Multidisciplinary investigation of an unusual apparent homicide/suicide.

The investigation of deaths of individuals whose bodies are decomposed, mummified, or skeletonized is particularly difficult for medical examiners and medicolegal death investigators. Determination of the cause and manner of death in such cases frequently requires consultation with experts in a variety of disciplines in the forensic sciences and necessitates correlation of the autopsy results, scene investigation, medical and social history of the deceased, and laboratory studies. The authors report an unusual case of an apparent homicide/suicide involving 2 individuals and a canine that went undetected for almost 4 years. Determination of the cause and manner of death in these cases involved a multidisciplinary, intercontinental investigation and necessitated the performance of toxicologic studies on specimens not commonly analyzed. These cases illustrate the importance of the multidisciplinary approach to medicolegal death investigations and the necessity of considering nontraditional sources of potential information and specimens for laboratory analysis in selected cases.

Household furniture tip-over deaths of young children.

The potential for the injury or death of a child resulting from the tip-over of a piece of household furniture or a domestic appliance has not been previously well recognized. We reviewed nine accidental deaths of young children that resulted from avoidable residential hazards and/or lapses in supervision of the children by their caregivers. The offending household items included televisions, bedroom dressers, a kitchen stove, and a lounge chair. The causes of death were mechanical asphyxia, blunt trauma, and combined blunt head trauma and asphyxia. All of the deaths could have been prevented by appropriate anchoring of the piece of furniture and/or closer supervision of the child. A thorough multidisciplinary investigation is essential in establishing the cause and manner of death in such cases and in identifying risk factors that may aid in the prevention of future childhood deaths.

Parasailing fatalities in southwest Florida.

Parasailing is a recreational sport that is generally considered to be of little risk to the participants. Typically, the passenger launches from a motorboat with a specially designed winch that pulls him or her back to the boat at the end of the ride. The sport is not regulated at the federal, state, or county level. There have been few reports of injuries to parasailors. Additionally, there have been only 2 fatalities reported to the United States Coast Guard in a 10-year review. We report the details of these 2 deaths, those of a mother and daughter riding in a tandem parasail, which occurred on Fort Myers Beach in 2001, as well as an additional case of a parasailing fatality that occurred in southwest Florida in 1999. These cases illustrate the injuries seen in such fatalities and the hazards posed by adverse weather conditions and faulty equipment, as well as the impairment of passenger judgment by drugs and/or alcohol.

Investigative and autopsy findings in sport aircraft-related deaths in southwest Florida.

Aircraft designated for sport or recreational use only, including ultralights, experimental aircraft and light-sport aircraft, have become increasingly popular. Because of their relative safety and the rarity of fatalities resulting from crashes of these aircraft, the forensic literature contains little information concerning the pathologic findings in such deaths. We report 9 deaths resulting from 6 sport aircraft crashes in southwest Florida, 6 pilots and 3 passengers. The vehicles involved 3 experimental aircraft, 1 ultralight and 2 "ultralight-like" aircraft. The patterns of injuries included trauma predominantly to the chest (3 cases), abdomen (1) or head (1), as well as multiple blunt force injuries involving the chest and abdomen (1) or the head and torso (3). Extremity fractures were found in only 2 cases, whereas injuries to the symphysis pubis were found in six. No "control-type" injuries were identified. These cases illustrate the varied pathologies associated with deaths due to crashes of sport aircraft and reveal the lack of uniformity associated with the investigations of such deaths.

Case report of suicide by inhalation of nitrogen gas.

Nitrogen is an inert gas that is a normal constituent of the air that we breathe. It is a suffocating gas that does not support life and that can be a cause of death by the displacement of oxygen in the atmosphere. The majority of deaths associated with nitrogen have occurred in the setting of scuba diving. Although other suffocating gases have been used as a means of committing suicide, the literature contains little information about the use of nitrogen as a suicidal agent. A case of a 50-year-old man who committed suicide using a homemade suicide device and nitrogen gas is presented.

Patterns of injury in a fatal BASE jumping accident.

Skydiving is a popular and relatively safe sport. The patterns of injury and mechanisms of death in the rare fatalities resulting from skydiving accidents have been well-documented. In contrast, BASE jumping, that is, jumping from a fixed object using a parachute, is a more dangerous and unregulated sport practiced by few individuals. There are no reports in forensic literature documenting the injuries found in deaths occurring in the practice of BASE jumping. We report the case of the death of an experienced BASE jumper who died after jumping from the antenna of a radio broadcast tower in southwest Florida to illustrate the unique hazards inherent in this sport.

Alligator attacks in southwest Florida.

The American alligator inhabits bodies of fresh water in Florida and other southeastern states. Although attacks on pets are frequent, alligator attacks on humans are relatively rare because of the animal's natural fear of man. Because of the rarity of attacks on humans, the pathologic findings and pathophysiology of death in such cases have not been well characterized in the literature. We report three cases of fatal alligator attacks that occurred in southwest Florida, each with different pathologic findings and mechanisms of death. Although the cause of death in each case was attributed to the alligator attack, the mechanisms of death differed and included exsanguination because of amputation of an extremity, overwhelming sepsis, and drowning. These cases illustrate the varied pathophysiologies associated with deaths due to alligator attacks on humans and the features that distinguish alligator bites from those of other aquatic predators.