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.

Paenibacillus Sepsis and Meningitis in a Premature Infant: A Case Report.

ABSTRACT: Infections due to bacteria of the genus Paenibacillus are exceedingly rare and therefore predominately described on a case-by-case basis. Here, we present a case of a 25-day-old premature neonate who died from presumed Paenibacillus sepsis and meningitis. Most prior reported cases of Paenibacillus bacteremia were among patients who had prosthetic medical devices, were immunocompromised, or were injection drug users. However, to our knowledge, this is the first reported case of infant death from presumed Paenibacillus thiaminolyticus. This case suggests the potential for severe human infection by an environmental bacterium previously considered to be of little consequence.

Improving Contagious Disease Reporting in a Medical Examiner's Office.

Contagious disease reporting is an important mechanism for public health officials to be informed of emerging and ongoing risks to the community's health. There are several mechanisms for reporting, including automated reporting from computer sources, required reporting from physicians and other health care professionals, and reporting of sales of certain over-the-counter medications such as cold remedies.Reporting by medical examiners is a significant source of information because contagious disease may first come to the medical examiner by causing sudden unexpected death. This study describes how the Los Angeles County Department of Medical Examiner-Coroner improved contagious disease reporting from coroner's cases. Methods used include computerized transmission to public health of initial coroner's case reports, e-mailed requests to the coroner to obtain cultures, having all results of coroner's cultures come through a single person who reports contagious disease as necessary, and including infectious disease screening in retrospective case review.

Postmortem Chikungunya Diagnosis: A Case Report and Literature Review.

Chikungunya is a mosquito-transmitted viral illness with clinical hallmarks of rash, fever, arthralgia, and myalgia. It is rarely fatal, although vulnerable populations, to include elderly, children, and those with multiple comorbid illnesses, are more susceptible to severe infection and death. There have been multiple areas of the world with periodic chikungunya epidemics. With increased immigration, foreign travel, epidemics, and global spread of the virus, it is prudent to consider chikungunya as a diagnosis both clinically and postmortem when a patient presents with rash, fevers, and arthralgia. We present a case of a patient with recent foreign travel, a rash, fever, and arthralgia with mosquito bites who succumbed to chikungunya viral infection with pneumonia. His diagnosis was established postmortem. A review of the literature is included in this report. This case stresses the delayed time to diagnose chikungunya with serologic testing and the importance of using reverse transcriptase-polymerase chain reaction to aid in rapid and accurate diagnosis and management.

COVID-19: Postmortem Diagnostic and Biosafety Considerations.

As a result of the 2019 novel human coronavirus (COVID-19) global spread, medical examiner/coroner offices will inevitably encounter increased numbers of COVID-19-infected decedents at autopsy. While in some cases a history of fever and/or respiratory distress (eg, cough or shortness of breath) may suggest the diagnosis, epidemiologic studies indicate that the majority of individuals infected with COVID-19 develop mild to no symptoms. Those dying with-but not of-COVID-19 may still be infectious, however. While multiple guidelines have been issued regarding autopsy protocol in cases of suspected COVID-19 deaths, there is some variability in the recommendations. Additionally, limited recommendations to date have been issued regarding scene investigative protocol, and there is a paucity of publications characterizing COVID-19 postmortem gross and histologic findings. A case of sudden unexpected death due to COVID-19 is presented as a means of illustrating common autopsy findings, as well as diagnostic and biosafety considerations. We also review and summarize the current COVID-19 literature in an effort to provide practical evidence-based biosafety guidance for medical examiner-coroner offices encountering COVID-19 at autopsy.

Sexual assault documentation program.

Since 2001, the Los Angeles County Department of Coroner has collaborated with Los Angeles County-University of Southern California Medical Center Violence Intervention Program and their Sexual Assault Center. The partnership was established at the suggestion of the district attorney's office to enhance the clinical recognition of sexual assault in the medical examiner's office using the extensive experience of experts in the field of sexual assault. As of December 2008, over 5 dozen victims of sexual assault have been evaluated with this collaboration. The partnership relied on the expertise of 2 pediatricians who are established clinical experts in the field of sexual abuse and assault, in collaboration with the staff of the medical examiner's office. In cases of suspected sexual assault, a joint evaluation by the clinical experts and the medical examiner was made. The goal of the project was for the medical examiners to become more confident in their observations and documentation of crimes of sexual abuse. Even though they are still available upon request, consultations with the sexual assault experts have decreased as the skills of the medical examiner to evaluate sexual assault cases have increased.

Forensic cardiac device analysis at the Los Angeles County Department of the Coroner: A 20-year experience.

Cardiac implantable electronic devices (CIEDs) store information continuously; however, the log of these devices is rarely analyzed in forensic practice. We retrospectively reviewed all cases referred for CIED interrogation by the Los Angeles County Department of Medical Examiner-Coroner between 2001 and 2020. According to the Department's practice, CIED interrogation may be requested for decedents in which details or cause of death are not clear from autopsy and clinical history. The CIED analysis was considered informative for the coroner's investigation either if it detected an arrhythmia or malfunction likely related to decedent's terminal event or if it was essential to determine time of death or identity of decedent. A total of 57 CIEDs were evaluated during the 20-year period. In almost half of cases (26/57: 45.6%), device analysis was informative for coroner's investigation. Arrhythmias likely related to terminal event were commonly detected (21/57: 36.8%). Device malfunction was identified as the likely cause of death in almost 10% of decedents (5/57: 8.8%), including three cases of battery depletion (3/57: 5.3%), one case of misclassification of ventricular tachycardia as supraventricular tachycardia with failure to deliver therapy (1/57: 1.7%), and one case of lead failure due to a broken pacing wire (1/57: 1.7%). Not infrequently, CIED interrogation was essential for determination of time of death (9/57: 15.8%), and there was one case (1/57: 1.7%) in which interrogation was essential for identifying the decedent. Our study shows that postmortem CIED interrogation can provide unique information regarding mechanism and time of death, and decedent's identity.

Blunt thoracic aortic injuries: an autopsy study.

OBJECTIVE: The objective of this study was to identify the incidence and patterns of thoracic aortic injuries in a series of blunt traumatic deaths and describe their associated injuries. METHODS: All autopsies performed by the Los Angeles County Department of Coroner for blunt traumatic deaths in 2005 were retrospectively reviewed. Patients who had a traumatic thoracic aortic (TTA) injury were compared with the victims who did not have this injury for differences in baseline characteristics and patterns of associated injuries. RESULTS: During the study period, 304 (35%) of 881 fatal victims of blunt trauma received by the Los Angeles County Department of Coroner underwent a full autopsy and were included in the analysis. The patients were on average aged 43 years±21 years, 71% were men, and 39% had a positive blood alcohol screen. Motor vehicle collision was the most common mechanism of injury (50%), followed by pedestrian struck by auto (37%). A TTA injury was identified in 102 (34%) of the victims. The most common site of TTA injury was the isthmus and descending thoracic aorta, occurring in 67 fatalities (66% of the patients with TTA injuries). Patients with TTA injuries were significantly more likely to have other associated injuries: cardiac injury (44% vs. 25%, p=0.001), hemothorax (86% vs. 56%, p<0.001), rib fractures (86% vs. 72%, p=0.006), and intra-abdominal injury (74% vs. 49%, p<0.001) compared with patients without TTA injury. Patients with a TTA injury were significantly more likely to die at the scene (80% vs. 63%, p=0.002). CONCLUSION: Thoracic aortic injuries occurred in fully one third of blunt traumatic fatalities, with the majority of deaths occurring at the scene. The risk for associated thoracic and intra-abdominal injuries is significantly increased in patients with thoracic aortic injuries.

Familicide-suicide: a cluster of 3 cases in Los Angeles County.

Familicide and familicide-suicide have not been extensively documented or adequately defined in forensic and psychiatric literature. Such incidents occupy a distinct epidemiological niche and are often precipitated by financial stressors. We present a cluster of 3 such cases, all of which occurred within a 4-month period in Los Angeles County, Calif. The dynamics of these cases are evaluated relative to the literature.

The choking game: a cause of unintentional strangulation.

A 12-year-old girl was brought to the pediatric emergency department by ambulance after her mother found her hanging from her bunk bed. The patient was resuscitated initially but died 5 days later after support was withdrawn. A sexual assault examination was performed, and the finding was negative. The case was investigated as a possible homicide or suicide. Upon questioning relatives, it was disclosed that the deceased had played the choking game. No one knew she had been playing the game alone. The choking game is popular with adolescents and is particularly dangerous when played alone. Emergency physicians should be aware of the characteristic warning signs that include frequent severe headaches, altered mental status after spending time alone, neck markings, and bloodshot eyes and counsel adolescents about the real risks associated with the activity. Accident, suicide, homicide, autoerotic behavior, and the "choking game" should be considered in the differential when an adolescent presents with evidence of strangulation.

Selecting forensic pathology as a career: a survey of the past with an eye on the future.

BACKGROUND: Each year there are about 30 to 40 physicians who train and become board-certified in the specialty area of forensic pathology, compared with hundreds or thousands in other disciplines. There are not enough board-certified forensic pathologists to cover national need. The National Association of Medical Examiners' (NAME) Forensic Pathology Training Committee conducted a survey of its members to determine which factors influenced them to select forensic pathology as a career, and to offer suggestions about possible recruitment methods in the future. METHODS: Two of the authors developed a 13-question survey form that included questions designed to determine the demographics of the responders, education level at which interest emerged, influential factors in the selection of forensic pathology, exposure to the subject matter of forensic pathology in medical school and residency, opinions about the best educational level for recruitment targeting, and faculty reactions to selection of forensic pathology as a career choice. Comments and suggestions were also solicited. The survey was sent by email to the 552 physician NAME members who have email addresses on file at the NAME Home Office. RESULTS: One hundred sixty-one surveys were returned for a response rate of 29%. Most responders were full-time, board-certified forensic pathologists who had been practicing for an average of 18 years. The most influential factors in developing interest were exposure to forensic pathology in residency training and the influence of a professor or mentor. Medical school was the favored education level to target recruitment. Less than half had a forensic pathologist as an autopsy instructor in anatomic pathology residency. The number of responders who were encouraged by faculty to pursue forensic pathology was about the same as the number who were either discouraged or who perceived no particular positive or negative reinforcement. The typical scenario for forensic pathology exposure during anatomic pathology residency was a 4-week rotation at an off-site location from the medical school or hospital, with a mentor that had an adjunct, assistant, associate, or clinical faculty appointment. CONCLUSIONS: If the past predicts the future, it will be important to ensure that pathology residents have a planned and positive exposure to forensic pathology and that forensic pathologist mentors are available to training programs. There are a variety of other methods that might be used for recruitment which include more emphasis on medical students, a more academic approach, and affiliation, emphasizing the scientific nature of the work, integrating forensic pathology more into the ongoing medical school curriculum, improving the anatomic pathology residency autopsy experience, and avoiding possible turnoffs that can be caused by presentation of sensational or unpleasant cases that are not representative of routine daily work. Improved remuneration and building esteem by peers were also cited as critical factors, as was recruitment of more physicians into pathology in general. The Committee intends to develop a plan for recruitment and retention in the field of forensic pathology. Based on the survey data, this will require a conjoined effort with the American Association of Medical Colleges, the Accreditation Council on Graduate Medical Education, the Association of Pathology Chairman, and other entities to enable a planned and multifaceted approach to recruitment and retention in the field.

Investigation of homicides interred in concrete--the Los Angeles experience.

Decedents interred in concrete present unique problems and investigation of these deaths necessitates a team of forensic specialists. The Los Angeles County Department of Coroner has had five such deaths in the past 18 years. The buried cases needed layer-by-layer excavation to establish the time and cause of death. Metal detectors are often used in this process. X-rays of the interred remains were completed to help with locating the decedent's position in the concrete. The breaking of concrete in some of the cases required the use of a sledgehammer and later a chisel in a manner that would not damage the remains. Postmortem dismemberment was frequent in our cases. The decedents were all female or prepubescent children, and the perpetrators were closely related to the decedents. While concrete can interfere with determination of postmortem interval, it can also preserve the remains and assist with identification.

Restraint asphyxia in in-custody deaths Medical examiner's role in prevention of deaths.

In the United States, the office of the Medical Examiner-Coroner is responsible for investigating all sudden and unexpected deaths and deaths by violence. Its jurisdiction includes deaths during the arrest procedures and deaths in police custody. Police officers are sometimes required to subdue and restrain an individual who is violent, often irrational and resisting arrest. This procedure may cause harm to the subject and to the arresting officers. This article deals with our experiences in Los Angeles and reviews the policies and procedures for investigating and determining the cause and manner of death in such cases. We have taken a "quality improvement approach" to the study of these deaths due to restraint asphyxia and related officer involved deaths, Since 1999, through interagency coordination with law enforcement agencies similar to the hospital healthcare quality improvement meeting program, detailed information related to the sequence of events in these cases and ideas for improvements to prevent such deaths are discussed.

Quality improvement of patient care - forensic pathologists' perspective.

In the U.S. today, the pathologists, both hospital-based and forensic, are regularly involved in quality assurance (QA) programs, the evaluation of patient safety at all levels of medical care, including treatments in walk-in clinics and medical offices. In the United States, official death investigations are conducted by the Medical Examiner's Office. The Medical Examiner's Office is aided in its work by a network of coordinating agencies to provide complete, comprehensive reporting and investigation of deaths placed under its jurisdiction. Those agencies are the Health Department, the Registrar of Vital Statistics on Births and Deaths, Division of Health Facilities, the Hospital Office of Decedent Affairs and the State medical licensing agencies, as well as the various law enforcement and regulatory agencies and the prosecuting attorney's office. Forensic pathologists are witnesses to the fatal results of often avoidable untoward events. They need to use their experiences to address and emphasize overall prevention programs to improve the quality of life in the community, to publicize the avoidable actions which can lead to untoward results. In the current growing atmosphere of threatening chemical, biological and radiation terrorist attacks, the health care system, especially hospitals, including emergency services, are mobilizing to develop plans to meet possible anticipated need for disaster preparedness.

The role of the forensic pathologist in quality assurance and safety of patient care.

During this past half century, there has been remarkable increase in the role of forensic pathologists and medical examiners in the determination of cause and manner of deaths in health care facilities and investigations of quality of patient care. Autopsy data are an essential part of this quality assurance (QA) program in patient care, especially in trauma centers' QA programs. Forensic pathologists participate in evaluating appropriateness of patient care where death occurs during or following therapeutic and diagnostic procedures. Continuous quality improvement programs now extend into data sharing in child and elder abuse, monitoring of defective medical devices and consumer products which contributed to deaths. In recent years, forensic pathologists are increasingly requested directly by family members to conduct private autopsies to provide independent opinions as to quality of patient care. Thus forensic pathologists are contributing expertise to an ever widening circle of influence in prevention of unnecessary deaths with quality assurance programs and peer review processes.

Fat transfer and fatal macroembolization.

Fat embolism is usually associated with long bone fractures or other trauma. The diagnosis is usually clinical, and in most cases, emboli are not fatal and not usually seen on gross examination. At the Los Angeles County Coroner's Office, we autopsied the victim of fatal macroscopic fat embolization to the lungs. The patient died during buttock enhancement surgery when fat from liposuction was injected into her buttocks. Fat embolism from liposuction and fat injection is reportedly rare, and macroscopic embolization is rarer still. Varicose veins can occur in the area of the sciatic notch and are known to cause painful sciatica symptoms. We suggest them as a potential conduit for macroscopic fat to reach the lungs. Simple pre-operative questioning for sciatica symptoms and possible radiologic study to rule out sciatic varices seem prudent before undertaking buttock-enhancing surgery. Careful fat injection with pre-aspiration is always advised.

Evolution of the psychological autopsy: fifty years of experience at the Los Angeles County Chief Medical Examiner-Coroner's Office.

The origin of the psychological autopsy was in the late 1950s and the result of a collaboration between the Los Angeles County Chief Medical Examiner-Coroner's Office and the Los Angeles Suicide Prevention Center. It was conceptualized as a thorough retrospective analysis of the decedent's state of mind and intention at the time of death. It was used initially in "equivocal" deaths where the manner of death was possibly either suicide or accident. Later, it was used in cases where a party (primarily family members) protested the Medical Examiner-Coroner's suicide determination. Over the past 25 years, the University of Southern California Institute of Psychiatry, Law, and Behavioral Science has served as the psychiatric/psychological consultants to the Coroner's Department. Research findings, the use of this approach in high-profile cases, and the most recent manner in which the psychological autopsy is conducted are discussed.

Fatalities of the 2008 Los Angeles train crash: autopsy findings.

INTRODUCTION: Train crashes represent a devastating multicasualty event. The purpose of this study was to analyze the injury severity, specific organ injuries, and cause of death in the fatalities of the 2008 Chatsworth, Los Angeles train crash. METHODS: This is a review of the medical examiner records of the 25 fatalities in the train crash. The Injury Severity (ISS) Score, body area with severe injuries (Abbreviated Injury Scale [AIS] > or = 4), specific organ injuries, and causes of death were recorded. The immediate cause of death was determined to be the most severe or most rapidly fatal injury in the opinion of the reviewers. RESULTS: A total of 25 fatalities occurred, including 24 victims who were pronounced dead at the accident scene and one who died 4 days later in the hospital. One victim did not undergo full autopsy. All of the decedents were located in the locomotive or in the passenger car immediately behind the locomotive. Overall, 15/24 decedents (63 percent) sustained unsurvivable injuries to at least one body region rendering an ISS of 75. The chest was the most severely injured body area (AIS > or = 4; 18/24, 75 percent), followed by the head (13/24, 54 percent), the extremities (11/24, 46 percent), and the abdomen (7/24, 29 percent). Spinal fractures were recorded in 17/24 (71 percent), and the cervical spine was the most commonly injured site. Thoracic aortic rupture was found in eight cases (33 percent) and cardiac ruptures in five cases (21 percent). CONCLUSIONS: The Metrolink train crash in 2008 in Chatsworth, Los Angeles, was the worst train crash in the history of California with 25 fatalities. The most common cause of death was due to chest injury (cardiac and aortic laceration) followed by head injury. This review could aid in improving passenger protection from head-on collision and in further development of head protection in train seats, as well as be useful in disaster planning and a benchmark for future rescue and triage operations.

Subaortic pseudoaneurysm of the left ventricle complicating staphylococcal endocarditis.

Subaortic pseudoaneurysms are rare but can be a cause of sudden death in young individuals. This case report involves a 20-year-old Vietnamese male who died suddenly from rupture of a subaortic pseudoaneurysm with resultant hemopericardium with tamponade. He had a history of bicuspid aortic valve with recent but healed Staphylococcal endocarditis. A review of the literature reveals few similar cases and enlightens the association between aortic bicuspid valve, endocarditis, and subvalvular aortic aneurysm. The pathogenesis as well as recent studies that identified aneurysm predisposing genes in patients with bicuspid aortic valve will be discussed.

Pacemaker/defibrillator evaluation at Los Angeles County Department of Coroner*.

Pacemakers and implantable cardioverter-defibrillators (ICDs) are implanted medical devices for the treatment of cardiac arrhythmias. These devices are now commonly encountered in the postmortem situation. The Los Angeles County Department of the Coroner uses the services of a cardiac electrophysiology consultant to interrogate pacemakers and ICDs, producing a detailed picture of the cardiac events recorded by the device. We have used this method to evaluate 20 cases where the ICD or pacemaker provided significant information. We report four forensic cases to illustrate the different applications of pacemaker interrogation and its contribution in forensic investigation. This technique was used to establish identification of the decedent, to determine the cause and time of death, and to determine whether device malfunction could have played a role in the death. We conclude that detailed evaluation of the pacemaker or ICD in selected cases may provide essential information to the forensic pathologist.