Evaluation of in-house drug evidence testing by King County Medical Examiner's Office in "real-time" fatal overdose surveillance.

With the escalating overdose epidemic, many surveillance efforts have appeared. In 2018, King County Medical Examiner's Office (KCMEO) initiated a fatal overdose surveillance project aimed at expediting death certification and disseminating timely information. In this project, KCMEO investigators collected items of evidence of drug use from overdose death scenes, which were tested by five in-house methods, four using handheld devices: TruNarc Raman spectrometer, with and without the manufacture's H-Kit, Rigaku ResQ Raman spectrometer, and MX908 mass spectrometer. The fifth in-house method used fentanyl-specific urine test strips. Results from in-house testing were compared with results from Washington State Patrol (WSP) Materials Analysis Laboratory. From 2019 to 2022, there were 4244 evidence items of drugs and paraphernalia collected from 1777 deaths scenes. A total of 7526 in-house tests were performed on collected specimens, and 2153 tests were performed by the WSP laboratory using standard analytical methods. The WSP results served as reference standards to calculate performance metrics of the in-house methods. Sensitivities, specificities, and predictive values ranged from good to poor depending on the method, drug, and evidence type. Certain drugs were often associated with specific evidence types. Acetaminophen was frequently found in combination with fentanyl. Fentanyl test strips gave good scores for detecting fentanyl; otherwise, in-house methods using handheld devices had poor performance scores with novel drugs and drugs diluted in mixtures. The results showed that in-house testing of drug evidence has value for medical examiner overdose surveillance, but it is resource intensive, and success depends on collaboration with forensic laboratories.

From intimate partners to serial killers: Nearly 40 years of female homicides in King County, Washington (1978-2016).

An extreme, known potential outcome of intimate partner violence (IPV) is death, with national data revealing females are more likely to be killed by intimate partners than by others. In a novel pairing, the King County Medical Examiner's Office data management system and the Washington State Attorney General's Office's Homicide Information Tracking System were retrospectively analyzed (1978-2016) with information gathered pertaining to female homicide victims. Analyses show that female victims commonly knew their assailant(s) (79.3%) who were overwhelmingly male (92.8%) and commonly intimate partners (31.4%). Disproportionately represented were Black (20.17%) and Native American (4.25%) females; Asian/Pacific Islander (2.5 times that of Whites) and elderly (24%) females among homicide-suicide deaths; and Asian/Pacific Islander and Hispanic females in cases of IPV. "Domestic violence" was the most cited motive (34.3%) and most assaults occurred in a residence (58.73%). Females under 10 years of age were most commonly killed by a parent or caregiver (42.86%), while those over 70 were most likely to be killed by a child (23.08%) or spouse (21.80%). Serial murders, most commonly by the Green River Killer (80%) but including others, accounted for at least 7% of deaths, with victims notably young and commonly sex workers (68%). As compared to males, females were more likely to be killed by multiple modalities, asphyxia, and sharp force, though IPV-related deaths were more likely to be associated with firearms. This study reinforces the vulnerability of females to IPV, sexual assault, and serial murders as well as to caretakers at the extremities of age.

Analysis of female strangulation homicides in King County, Washington, from 1978 to 2022.

Asphyxia due to strangulation is an uncommon but important modality of homicide that tends to disproportionately involve female victims. The present study was designed to investigate the circumstances, motivations, and injuries associated with strangulation homicides of females and to measure trends in incidence over time. Electronic records of the King County Medical Examiner's Office in Seattle, Washington, were used to compile a data set of all homicides in King County from 1995 through 2022. A second data set of female homicides due to strangulation was constructed with additional records prior to 1995, supplemented with data abstracted from autopsy reports, and linked to the Washington Attorney General's Office Homicide Investigation Tracking System database. This comprehensive data set was used to analyze demographics, circumstances, motives, and injuries of female strangulation homicides from 1978 through 2016. The results found that, from 1995 through 2022, females accounted for 22.8% of 2394 homicides but 80.3% of strangulation homicides. The average annual rate of all strangulation homicides decreased until 2020. Mean ages of female decedents were 27.7 years in homicides associated with sexual assault, 36.8 years with domestic violence, and 63.9 years with robbery. Lethal assaults most often occurred in private homes, and perpetrators were usually well known to the victim. Injuries included petechiae in 83%; ligature marks in 20%; fingernail marks in 1.4%; hyoid fractures in 23%; and thyroid cartilage fractures in 31%. Fractures were more common in manual strangulation and in decedents of ages over 40 years.

Medical examiner response to the drug overdose epidemic in King County Washington: "Real-time" surveillance, data science, and applied forensic epidemiology.

As the overdose epidemic overwhelmed medicolegal death investigation offices and toxicology laboratories, the King County Medical Examiner's Office responded with "real-time" fatal overdose surveillance to expedite death certification and information dissemination through assembling a team including a dedicated medicolegal death investigator, an information coordinator, and student interns. In-house testing of blood, urine, and drug evidence from scenes was performed using equipment and supplies purchased for surveillance. Collaboration with state laboratories allowed validation. Applied forensic epidemiology accelerated data dissemination. From 2010 to 2022, the epidemic claimed 5815 lives in King County; the last 4 years accounted for 47% of those deaths. After initiating the surveillance project, in-house testing was performed on blood from 2836 decedents, urine from 2807, and 4238 drug evidence items from 1775 death scenes. Time to complete death certificates decreased from weeks to months to hours to days. Overdose-specific information was distributed weekly to a network of law enforcement and public health agencies. As the surveillance project tracked the epidemic, fentanyl and methamphetamine became dominant and were associated with other indicators of social deterioration. In 2022, fentanyl was involved in 68% of 1021 overdose deaths. Homeless deaths increased sixfold; in 2022, 67% of 311 homeless deaths were due to overdose; fentanyl was involved in 49% and methamphetamine in 44%. Homicides increased 250%; in 2021, methamphetamine was positive in 35% of 149 homicides. The results are relevant to the value of rapid surveillance, its impact on standard operations, selection of cases requiring autopsy, and collaboration with other agencies in overdose prevention.

Medical Examiner Surveillance of the COVID-19 Pandemic in King County, Washington, USA.

ABSTRACT: The King County Medical Examiner's Office in Seattle, Wash, initiated a surveillance project with a dedicated team and database tracking the spread of severe acute respiratory syndrome coronavirus 2, deaths due to coronavirus disease 2019 (COVID-19), and deaths occurring within 28 days of COVID-19 vaccination. From January 2020 through July 2022, the results of 13,801 nasal/nasopharyngeal swabs from 7606 decedents tested for the virus were assembled in the surveillance database. Generally, 2 samples were collected and tested separately by 2 different laboratories. Positive rates increased from 5.7% in 2020 to 14.3% in 2022. Of 744 decedents positive for the virus, autopsies were performed on 418 (56%); of these, 106 (25%) died of COVID-19 as either the primary or a contributing cause. Comparison of autopsy findings of those dying of COVID-19 with those positive for the virus but dying of other causes demonstrated increased risk for those with preexisting conditions. Of 1035 deaths reported within 28 days of vaccination, the rates of thrombotic complications and myocarditis were no higher than in other decedents. This study provides evidence of the value to public health surveillance of an adequately resourced medical examiner office in tracking viral spread in the community, understanding disease mortality, and assessing vaccine safety.

Globus Pallidus Necrosis Unrelated to Carbon Monoxide Poisoning: Retrospective Analysis of 27 Cases of Basal Ganglia Necrosis.

Bilateral globus pallidus necrosis is said to be characteristic of carbon monoxide (CO) poisoning. However, there has been no scientific test of this hypothesis. To examine the assertion that globus pallidus necrosis is typical of CO poisoning, this study examined autopsy cases from the King County Medical Examiner's Office (KCMEO) between 1994 and 2013. Twenty-seven cases with bilateral basal ganglia lesions were identified and examined for associated or causative disease or injury with the following results: 10 cases of drug overdose, seven heart disease, three asphyxia, two chronic ethanolism, two Huntington-like disorder, and one case each of remote trauma, rheumatic heart disease, and cerebral artery gas embolism. Additionally, review of all known cases at KCMEO of CO poisoning found no evidence of globus pallidus or basal ganglia necrosis. Thus, this study provides no support for the assertion that globus pallidus necrosis is characteristic of CO poisoning.

Relation of kinetic energy to contact wounds of the head by centerfire rifles and shotgun slugs.

Wounds of high-energy centerfire rifles and shotguns represent distinctive injuries of forensic importance. Previous studies of contact wounds have shown variability in the potential of these weapons to produce bursting wounds of the head. The present study analyzed contact head wounds owing to 26 centerfire rifles and nine shotgun slugs and compared them with respect to weapon, ammunition, entry wound site, and projectile kinetic energy. The bursting effect, defined for this study as disruption of at least 50% of the head, occurred in 25/35 of cases and was related to kinetic energy. Bursting was associated with energies <2700 ft-lbs in 12/22 cases and energies >2700 ft-lbs in 13/13 cases. The volume of gunpowder gas injected into the wound was considered as contributing to the bursting phenomenon. There was no relation of bursting to the specific entrance wound site, type of ammunition, or projectile fragmentation.

Peliosis hepatis presenting as liver rupture in a vulnerable adult: a case report.

Liver rupture is a serious, life-threatening event that is commonly due to blunt abdominal trauma, which should be suspected in a patient who is unconscious or unable to communicate. We report an autopsy case of a 28-year-old woman with severe developmental delay who presented to the emergency department with hemoperitoneum due to massive liver rupture and subsequently died without a diagnosis. An autopsy performed by the hospital pathology department confirmed hemoperitoneum due to hepatic rupture. The case was then referred to the medical examiner to exclude a traumatic etiology. After review of the clinical data, radiological images, and gross and microscopic pathological features, a diagnosis of peliosis hepatis was established. This rare entity has been reported previously as a cause of spontaneous, nontraumatic liver rupture and is reported here to demonstrate its characteristic features and potential to present as fatal hepatic rupture in circumstances in which occult injury must be excluded.

Trends in suicide by carbon monoxide inhalation in King County, Washington: 1996-2009.

Carbon monoxide (CO) inhalation is one of the leading methods of suicide in the United States. A sharp increase in suicide by inhaling the CO produced from burning charcoal has been reported in parts of Asia; however, the incidence of this method has not been determined in a U.S. population. Thus, we determined trends of CO suicide in the ethnically diverse population of King County, Washington, U.S.A. During the period 1996-2009, we identified 158 cases of suicide by CO poisoning, with 125 because of automotive exhaust, 26 because of charcoal burning, and seven from other CO sources. While historical U.S. data indicate >99% of CO suicides in the United States occurring by automobile exhaust inhalation, in the most recent years analyzed, c. 40% of CO-related suicides in King County, Washington, were because of charcoal burning, indicating a possible shift in suicide trends that warrants further scrutiny in additional populations.

Elderly deaths due to ground-level falls.

This study analyzed 237 fatal ground-level falls occurring in decedents aged 65 years or older reported to the Seattle-King County Medical Examiner's Office during the year 2007. Head injuries accounted for 109 (46%) of the deaths, and nonhead injuries accounted for 128 (54%) of the deaths. Falls occurred in similar locations in both groups. Compared with those of nonhead injuries, decedents of head injuries were younger (82 vs 87.5 years), were more often male (58% vs 45%), died sooner after their injury (9 days vs 23 days), and were more likely treated with anticoagulants, especially warfarin (48% vs 16%). Subdural hematoma was the most common specific traumatic lesion, occurring in 86% of the decedents of head injury; skull fractures occurred in 13%. Decedents of head injury who were treated with anticoagulants, on average, sustained less severe head injury than those who were not treated with anticoagulants.

Necrotizing fasciitis: manifestations, microbiology and connection with black tar heroin.

A 10-year review of records of the King County Medical Examiner's Office found 87 deaths due to necrotizing fasciitis and related necrotizing soft tissue infections. In 64 of these cases there were sufficient details to provide an analysis of the manifestations, microbiology, and source of infection. One half (32) of the cases were due to injection of black tar heroin, the nearly exclusive form of heroin in the Northwest United States. Of those due to black tar injection, 24 were clostridial infections with various species represented, eight of which were Clostridium sordellii. Of the 32 cases not associated with drug injection, streptococcal species predominated, with Streptococcus pyogenes isolated in 14 cases. Only three of 32 cases not associated with injection drug use were clostridial infections. These differences were statistically significant. Staphylococcus aureus was isolated from 14 cases; two were methicillin-resistant strains. Overall, 28 of the 64 cases were polymicrobial infections, 15 due to black tar injection and 13 not associated with drug injection. This study supports the conclusion that necrotizing fasciitis due to black tar heroin injection is predominantly a clostridial disease, and in this way differs significantly from necrotizing fasciitis due to other causes.

Tramadol (Ultram) concentrations in death investigation and impaired driving cases and their significance.

We reviewed a series of 66 deaths in Washington State between 1995-2000 in which tramadol (Ultram and Ultracet, Ortho-McNeil) was detected in the decedent's blood, in order to assess the role tramadol was determined to have played. Additionally, we reviewed a series of 83 impaired driving cases in which tramadol was detected in order to establish a non-lethal blood tramadol concentration reference range. In both populations, tramadol was consistently found together with other analgesic, muscle relaxant, and CNS depressant drugs. Death was rarely attributable to tramadol alone. However, tramadol may be a significant contributor to lethal intoxication when taken in excess with other drugs, via the potential interaction with serotonergic antidepressant medications, as well as the potential for increased CNS depression. Although the incidence of tramadol detection has increased consistently over the last eight years, there is no evidence of a corresponding increase in the number of cases in which death was attributed solely to tramadol. Blood drug concentrations in many deaths exceeded the therapeutic serum range of 0.28-0.61 mg/L; however, the concentrations overlapped almost completely with the range identified in living subjects arrested for impaired driving. These findings suggest caution in the interpretation of blood tramadol concentrations outside of the recognized therapeutic range. It also suggests that the drug, even when used in moderate excess, is not a principle cause of death in suicidal or accidental deaths.

Unexpected hazard of illegal immigration: Outbreak of viral myocarditis exacerbated by confinement and deprivation in a shipboard cargo container.

We present a group of 18 illegal immigrant stowaways who arrived in a shipboard cargo container suffering from gastroenteritis, dehydration, and malnutrition and showing evidence of viral myocarditis in 3 of 4 fatalities. Our investigation included an evaluation of the 2-week ocean voyage, analysis of medical records and laboratory results of the survivors, autopsies on the decedents, and viral studies on their heart tissue. Of 3 stowaways who died shipboard, 2 showed lymphocytic myocarditis and 1 could not be evaluated histologically due to decomposition. A fourth stowaway died 4 months after arrival with dilated cardiomyopathy and lymphocytic myocarditis. Reverse-transcriptase polymerase chain reaction and nucleotide sequencing of viral isolates from the decedents' heart tissues demonstrated Coxsackie virus B3 genome. We believe that these cases represent an outbreak of viral myocarditis, exacerbated by acute dehydration and malnutrition, due to confinement within the shipping container. Our evidence indicates that close confinement promoted the spread of the virus, and nutritional deprivation increased the stowaways' vulnerability. Furthermore, our observations support the conclusion, based on experimental studies, that nutritionally induced oxidative stress increased the virulence of the etiologic viral agent. In summary, these cases represent a potential infectious disease hazard of illegal immigration.

Validation of chest X-ray comparisons for unknown decedent identification.

Comparing skeletal structures between antemortem and postmortem chest radiographs is widely used by forensic specialists from many disciplines to positively identify unknown decedents. However, validity assessments of this method have been fairly limited. This study had three objectives: 1) to quantify the reliability of ante- and postmortem chest radiograph comparison for decedent identification; 2) to identify useful radiologic features supporting decedent identification; and 3) to recognize sources of error in decedent identification related to use of comparative radiographs. A forensic pathologist, a forensic anthropologist, and two radiologists participated in the study. Our results showed that chest radiograph comparisons proved reliable, if basic decedent information was provided, and antemortem and postmortem radiographs were adequately positioned and exposed. A "morphological approach" using normal anatomical structures for comparison may provide the most efficient method for accurate identification.