HIPAA and Access to Medical Information by Medical Examiner and Coroner Offices.

Often, medical staff and sometimes their attorneys mistakenly believe that HIPAA prevents disclosure of medical records to medical examiner and coroner offices. Medical examiner and coroner government offices are not covered entities. Moreover, HIPAA specifically allows disclosure to law enforcement, public health, and medical examiner and coroners. However, state and Joint Commission requirements may further impact disclosures.

A Model Medical Examiner Law.

Background: Legal systems for medicolegal death investigation in the United States are varied. A 1954 model medical examiner law was initially embraced by a few states but did not gain widespread support and was woefully inadequate. The 2009 National Commission on Forensic Science recommended the creation of an updated model medical examiner legislation. Methods: Various considerations for policymakers are explored. Results: A model law is proposed.

Severe Acute Respiratory Syndrome Coronavirus 2 Antibody Seroprevalence in Decedents Undergoing Forensic Postmortem Examination: Feasibility for Real-Time Pandemic Surveillance.

Background: Population-based seroprevalence studies offer comprehensive characterization of coronavirus disease 2019 (COVID-19) spread, but barriers exist and marginalized populations may not be captured. We assessed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antibody seroprevalence among decedents in Maryland over 6 months in 2020. Methods: Data were collected on decedents undergoing forensic postmortem examination in Maryland from 24 May through 30 November 2020 from whom a blood specimen could be collected. Those with available blood specimens were tested with the CoronaCHEK lateral flow antibody assay. We assessed monthly seroprevalence compared to the statewide estimated number of cases and proportion of positive test results (testing positivity). We used Poisson regression with robust variance to estimate adjusted prevalence ratios (aPRs) with 95% confidence intervals (CIs) for associations of demographic characteristics, homelessness, and manner of death with SARS-CoV-2 antibodies. Results: Among 1906 decedents, 305 (16%) were positive for SARS-CoV-2 antibodies. Monthly seroprevalence increased from 11% to 22% over time and was consistently higher than state-level estimates of testing positivity. Hispanic ethnicity was associated with 2- to 3.2-fold higher seropositivity (P < .05) irrespective of sex. Deaths due to motor vehicle crash were associated with 62% increased seropositivity (aPR, 1.62 [95% CI, 1.15-2.28]) vs natural manner of death. Though seroprevalence was lower in decedents of illicit drug overdose vs nonoverdose in early months, this shifted, and seroprevalence was comparable by November 2020. Conclusions: Decedents undergoing forensic postmortem examination, especially those dying due to motor vehicle trauma, may be a sentinel population for COVID-19 spread in the general population and merits exploration in other states/regions.

The Impact of Skin Color on the Recognition of Blunt Force Injuries.

ABSTRACT: Dark skin may obscure injuries. This is reflected in the illustrations in textbooks, which generally depict blunt force injuries in victims with light skin tones. We explored whether forensic pathologists can reliably recognize blunt force injuries in dark-toned skin by comparing the average number of contusions and abrasions of motor vehicle accident victims with dark- and light-toned skin. We also investigated whether the race of the forensic pathologist observer mattered. We found a significant difference in the number of injuries recorded in autopsies of motor vehicle accident victims based upon skin tone; there was also a difference in the race of the observer.

Requests to Amend Cause and Manner of Death Determinations by Medical Examiners in Maryland, 2015-2021.

ABSTRACT: A 1989 state law in Maryland allows family members to contest cause and manner of death determinations of medical examiners. A previous article described the experience with this law involving 12 appeals over a 3-year period (2012-2015). We now update the experience with the law involving 10 appeals that occurred over a subsequent period (2015 to September 2021) and a resultant change in the law. This unique appellate scheme has proven to be a valuable tool for medical examiners and families and has to date prevented resort to judicial courts. It is a model statutory scheme that is recommended for other jurisdictions to consider.

Loss of Nuclear Basophilic Staining as a Postmortem Interval Marker.

INTRODUCTION: The loss of basophilia (LOB), as an objective marker of postmortem interval (PMI), was evaluated. Such a correlation has been previously reported in stillborn fetuses. METHOD: Loss of basophilia in different tissues was scored using hematoxylin and eosin-stained slides obtained from 65 random autopsy cases. Scatter plots were used to visually assess the correlation of PMI with our LOB scores. Decomposition was assessed using a modified total body score. RESULTS: Loss of basophilia was found to be correlated with PMI (total and unrefrigerated intervals). Specifically in this study, we found full or partial basophilic staining up to 26 hours after death, and complete LOB was seen in cases as early as 36 hours in liver and 60 hours in heart. Loss of basophilia also well correlated with the modified total body score. The LOB varied by tissue and was uncorrelated to histologically observable bacteria and fungi. Refrigeration appeared to stop the autolytic process that causes the LOB. CONCLUSION: Complete LOB can be expected between 1 and 2 days after death in unrefrigerated liver and heart tissues because of autolysis.

Fentanyl-related substance scheduling as an effective drug control strategy.

Fentanyl is now the primary driver of the current opioid crisis. Fentanyl and its analogues are subject to the Controlled Substances Act of 1970, the Controlled Substances Analogue Enforcement Act of 1986 (Federal Analogue Act), state laws, international treaties, and the laws of foreign countries. The appearance of novel psychoactive substances led to further legislative developments in scheduling. New fentanyl analogues proliferated in a manner previously unseen since about 2016. Overdose deaths of these fentanyl analogues prompted the Drug Enforcement Administration to reactively emergency schedule each new fentanyl analogue as it appeared. The international community also acted. Finally, on February 6, 2018, a proactive temporary (emergency) class-wide scheduling of fentanyl-related substances was implemented based upon the fentanyl core structure to save lives. This action spurred a similar action in China. Fentanyl analogues fell dramatically in the marketplace, despite further increases in fentanyl itself. Congress temporarily extended this scheduling, but it will soon expire. Opposition to permanent class-wide was lodged due to concerns over law enforcement overreach, inadequate Health and Human Services input, and hindrance of research. This paper reaffirms the importance of a class-based scheduling strategy while also arguing for increased research of schedule I controlled substances.

Bases of Forensic Pathology Expert Testimony With Emphasis on Iowa v Tyler.

Judicial scrutiny of the forensic sciences is increasing. This scrutiny targets the bases for expert opinions. Forensic pathologists must understand that when they express an opinion it must have an articulable underlying basis. Iowa v Tyler provides a cautionary tale where testimony from a forensic pathologist on the cause and manner of death based exclusively on police reports and audio and video recordings of police interviews of the suspect rather than on medical evidence were held to be inadmissible. Tyler has an odd and distinguishable set of facts, but has been widely cited as an example of problematic forensic pathology testimony.

Origins of the Armed Forces Medical Examiner System.

The Armed Forces Medical Examiner System (AFMES) is the only medicolegal death investigation system of the US federal government. Its origins can be traced to three dried tissue specimens placed on a shelf by a Civil War Surgeon General in 1862. The collections and the library of the Army Surgeon General spawned the Armed Forces Institute of Pathology (AFIP), the National Museum of Health and Medicine, the Walter Reed Army Institute of Research, and the National Library of Medicine. Pathologists of the Army Medical Museum performed the autopsies of assassinated Presidents Lincoln and Garfield and assisted with that of Kennedy. The now defunct AFIP created the first forensic pathology training program approved by the American Board of Pathology and then the AFMES. Col Ed Johnston, CAPT Charlie Stahl, and Col Dick Froede were the original pioneers of the AFMES.

Reclaiming the Autopsy as the Practice of Medicine: A Pathway to Remediation of the Forensic Pathology Workforce Shortage?

The historically constricted forensic pathology workforce pipeline is facing an existential crisis. Pathology residents are exposed to forensic pathology through the American Council of Graduate Medical Education autopsy requirement. In 1950, autopsies were conducted in one half of the patients dying in American hospitals and 90% in teaching hospitals, but they have dwindled to fewer than 5%. Elimination of funding for autopsies is a major contributor to the lack of support for autopsies in departments of pathology. Funding may require reclaiming the autopsy as the practice of medicine. Funding of autopsies would rekindle interest in hospital autopsies and strengthen the forensic pathology workforce pipeline.

Justice Denied: Low Submission Rates of Sexual Assault Kits and the Predicting Variables.

Following sexual assaults, victims are advised to seek health care services with forensic evidence collected and packaged in sexual assault kits (SAKs). This large (N = 1,874), retrospective study examined rates of SAK submissions by law enforcement to the state crime laboratory for analysis from 2010 to 2013 at four sites in a Western state in the United States with established sexual assault nurse examiner (SANE) programs. Variables of legal and extralegal characteristics in sexual assault cases were explored through generalized estimating equations (GEE) modeling to determine what factors statistically predicted SAK submissions. For submitted SAKs, the length of time between the dates of assault and dates of submission was categorized, and bivariate and multivariate analyses were calculated to discover legal and extralegal characteristics affecting time of submission. The study sites represented 40% of the state's law enforcement agencies and 65% of the state's population. Out of the 1,874 SAKs in the study, only 38.2% were submitted by law enforcement to the state crime laboratory for analysis. When SAK submissions were examined based on time between assaults and submission dates, 22.8% were submitted within a year of the assault and 15.4% were submitted more than a year after the assault following media and community pressure for law enforcement agencies to submit SAKs in storage. Significant variability of SAK submission rates and the time submitted from the assault dates were found between the sites. Site location was found to be the main determinant of whether or not SAKs were submitted. The lack of SAK submissions for analysis results in justice denied for victims and raises public safety concerns. The finding that the location in which the sexual assault occurred was the primary factor on SAK submissions represents an inequity of justice.

Characteristics of medical examiner/coroner offices accredited by the National Association of Medical Examiners.

The National Association of Medical Examiners accredits medical examiner and coroner offices. Approximately 60 offices were fully or provisionally accredited as of late 2011, and these offices serve one-quarter of the U.S. population. The calculated average population served was 1.6M but ranged from 0.3 to 10.5M. The calculated mean death rate was 794 deaths/100K population, and the mean homicide rate was 7.2 homicides/100K population. The calculated mean budget was $4.35M, but budgets ranged from $0.67 to $26.8M. The calculated mean budget/capita was $3.02 but ranged from $0.62 to $10.22. The average size of the facility was under 30,000 sq. ft. The calculated average staffing was found to include five forensic pathologists, four and a half autopsy technicians, and nine investigators. The mean forensic pathologists/1M population was 3.7. Calculated workload indices included 222 autopsies/pathologist and an autopsy rate of 77.6/100K population. These results show that offices of every size can achieve accreditation.

DNA identification in mass fatality incidents.

DNA identification has become an important aspect of mass fatality management as well as in other instances of difficult identification of human remains. Most large mass fatality incidents will require DNA identification. Medical examiners should prepare for such potential eventuality. Whether DNA is tested, in mass fatality incidents, DNA specimens should be obtained from remains as well as from next-of-kin for potential testing. DNA identification is neither as slow nor as expensive relative to the overall fatality management as is commonly assumed. This article sought to provide medical examiners with a framework for DNA identification in mass fatality incidents.

Microdialysis of proteins: performance of the CMA/20 probe.

Unlike all other currently available sampling techniques, microdialysis allows the continuous recovery of dialysed fluid from the interstitial space of living tissue. Microdialysis has been extensively used to study small molecules such as neurotransmitters, metabolites and drugs in the brain and other tissues. There has been increasing interest in measuring proteins using microdialysis. Optimizing protein recovery requires slow buffer flow rates, large pore membranes and osmotic balancing. An examination of a widely used commercially available large pore (100kDa MWCO) polymeric microdialysis probe, the CMA/20 (polyethersulfone) over 6 days of continuous microdialysis showed that: (1) published molecular weight cut-off values may not predict the size of proteins that can be recovered. This membrane had an effective molecular weight cut-off values (MWCO) of about 29kDa, (2) protein recoveries decrease over time, (3) small proteins are much less affected than larger ones and (4) there can be significant differences in the recovery of proteins similar in size perhaps due to reaching of a critical size, protein aggregation, shape, surface charge or hydrophobicity.

A comprehensive analysis of forensic science training in forensic pathology fellowship programs.

The purpose of this study is to assess the current nature and extent of forensic science training in the nation's 43 Accreditation Council for Graduate Medical Education (ACGME)-accredited forensic pathology fellowship programs. This manuscript describes the results of a survey of training program directors performed as a project for the College of American Pathologists (CAP) Forensic Identity Committee. The results show a considerable diversity in the forensic sciences training in forensic pathology programs, ranging from one to ten weeks, with an average of 4.1 weeks. However, almost one half of programs provide no training in at least one of the surveyed disciplines. Only 58.1% of responding programs meet the ACGME requirements for forensic science training, and a similar percentage (56.0%) currently provides the duration of forensic science training recommended by the National Association of Medical Examiners (NAME). The deficit in the NAME training recommendations, surprisingly, was strictly in the field of toxicology.