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.

Long gun suicides in the state of Maryland following the firearm safety act of 2013.

OBJECTIVES: In 2013, the state of Maryland passed the Firearms Safety Act limiting the private sales of handguns, which did not apply to long guns often used for hunting (e.g., rifles and shotguns). This decreased the accessibility of handguns relative to long guns. We assessed the frequency of long gun suicides in the years before and after the policy change during winter season, which encompasses hunting season in Maryland. METHODS: We performed a retrospective analysis on all 4107 well-characterized adult suicides caused by firearms in Maryland from 2003 through 2019. Logistic regression was performed, stratifying by decedent sex, race, and age. RESULTS: While handgun suicides decreased in the period after 2013's Firearm Safety Act (p < 0.008), wintertime long gun suicides increased after 2013 (p < 0.004). Caucasian race (p < 0.006), male sex (p < 0.005), and middle age (p < 0.001) were significantly associated with wintertime long gun suicides after 2013. CONCLUSION: Our findings suggest that while the 2013 Firearms Safety Act decreased handgun suicides significantly, it did not reduce long gun suicides and there may even have been replacement with long guns during hunting season, when rifles are out and accessible. This association was most prominent among the demographics most likely to hunt (Caucasian, middle-aged, and male).

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.

Prone restraint cardiac arrest in in-custody and arrest-related deaths.

We postulate that most atraumatic deaths during police restraint of subjects in the prone position are due to prone restraint cardiac arrest (PRCA), rather than from restraint asphyxia or a stress-induced cardiac condition, such as excited delirium. The prone position restricts ventilation and diminishes pulmonary perfusion. In the setting of a police encounter, metabolic demand will be high from anxiety, stress, excitement, physical struggle, and/or stimulant drugs, leading to metabolic acidosis and requiring significant hyperventilation. Although oxygen levels may be maintained, prolonged restraint in the prone position may result in an inability to adequately blow off CO2 , causing blood pCO2 levels to rise rapidly. The uncompensated metabolic acidosis (low pH) will eventually result in loss of myocyte contractility. The initial electrocardiogram rhythm will generally be either pulseless electrical activity (PEA) or asystole, indicating a noncardiac etiology, more consistent with PRCA and inconsistent with a primary role of any underlying cardiac pathology or stress-induced cardiac etiology. We point to two animal models: in one model rats unable to breathe deeply due to an external restraint die when their metabolic demand is increased, and in the other model, pressure on the chest of rats results in decreased venous return and cardiac arrest rather than death from asphyxia. We present two cases of subjects restrained in the prone position who went into cardiac arrest and had low pHs and initial PEA cardiac rhythms. Our cases demonstrate the danger of prone restraint and serve as examples of PRCA.

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.

Blinded review of hippocampal neuropathology in sudden unexplained death in childhood reveals inconsistent observations and similarities to explained paediatric deaths.

AIMS: Hippocampal findings are implicated in the pathogenesis of sudden unexplained death in childhood (SUDC), although some studies have identified similar findings in sudden explained death in childhood (SEDC) cases. We blindly reviewed hippocampal histology in SUDC and SEDC controls. METHODS: Hippocampal haematoxylin and eosin (H&E) slides (n = 67; 36 SUDC, 31 controls) from clinical and forensic collaborators were evaluated by nine blinded reviewers: three board-certified forensic pathologists, three neuropathologists and three dual-certified neuropathologists/forensic pathologists. RESULTS: Among nine reviewers, about 50% of hippocampal sections were rated as abnormal (52.5% SUDC, 53.0% controls), with no difference by cause of death (COD) (p = 0.16) or febrile seizure history (p = 0.90). There was little agreement among nine reviewers on whether a slide was within normal range (Fleiss' κ = 0.014, p = 0.47). Within reviewer groups, there were no findings more frequent in SUDC compared with controls, with variability in pyramidal neuron and dentate gyrus findings. Across reviewer groups, there was concordance for bilamination and granule cell loss. Neither SUDC (51.2%) nor control (55.9%) slides were considered contributory to determining COD (p = 0.41). CONCLUSIONS: The lack of an association of hippocampal findings in SUDC and controls, as well as inconsistency of observations by multiple blinded reviewers, indicates discrepancy with previous studies and an inability to reliably identify hippocampal maldevelopment associated with sudden death (HMASD). These findings underscore a need for larger studies to standardise evaluation of hippocampal findings, identifying the range of normal variation and changes unrelated to SUDC or febrile seizures. Molecular studies may help identify novel immunohistological markers that inform on COD.

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.