Exsanguination From Superficial Lower Extremity Trauma.

ABSTRACT: Deaths related to exsanguination are not rare; however, most are related to large-caliber blood vessel or organ disruption. This article reports 2 deaths from external hemorrhage arising from superficial lower extremity trauma in persons with peripheral vascular disease and anticoagulant therapy. The first involved a 78-year-old woman who was found unconscious in her home by a relative, with a plastic bag tied around her left foot and evidence of profuse hemorrhage arising from a left great toenail partial avulsion injury. The second involved a 48-year-old male resident of an adult group home who was involved in a physical altercation with a group home employee, who reportedly kicked the decedent in the right shin, resulting in extensive hemorrhage and death. The cases highlight the fact that lethal exsanguination can occur from superficial trauma. Persons with peripheral vascular disease and those taking anticoagulants may be at particular risk for such deaths.

"Comet-tailing" associated with gunshot entrance wounds.

A "plated bullet" has a thin layer of electroplated metal covering the lead core of the projectile. In certain situations, this thin layer of electroplated metal can fracture upon discharge of the firearm. When such fracturing occurs, vaporous lead can escape through the fracture lines of the spinning projectile, resulting in a spiral-shaped deposition of dark residue surrounding a central bullet defect. The spiral-shaped pattern is referred to as "comet-tailing," or the "vortex effect." In this report, three homicide cases with associated comet-tailing are presented. Police, death investigators, and forensic pathologists should be aware of this unique finding.

Homicides Disguised as Staged Suicides.

Determining the correct cause and manner of death are among the chief responsibilities of the forensic pathologist. When confronted with a case having a questionable manner of death, it is important for scene evidence, witness statements, and forensic autopsy findings to be thoroughly reviewed before certifying the manner of death. Herein three gunshot wound cases are presented which initially were suspected to be suicides but were instead determined to be homicides through full investigations with correlation to autopsy findings.

Hostage Situation Homicide.

Deaths related to hostage situations occur in many forms, as these situations can easily escalate as a result of many confounding variables. When approaching such cases, forensic pathologists and death investigators should be mindful of the many details that should be well-documented at the scene and during autopsy to ensure that the correct conclusions and death certification are determined. This case report highlights a death in a hostage situation and the importance of correlating scene information and autopsy findings. An elderly female hostage was ambulating with a walker away from her ex-husband's home, after police negotiations successfully convinced her ex-husband to release her. The ex-husband then appeared at the door, brandishing a weapon, at which time a police officer shot at the man. Instead of striking the man, the rifle's projectile struck the woman in the chest. Subsequent investigation revealed that, although the police officer had a "clear shot" via the rifle sights, the muzzle end of the rifle was obstructed by the back corner of an automobile, behind which the officer was positioned during the hostage situation standoff. The case highlights a rarely discussed safety rule related to firearms: recognition that the line of sight via a weapon's sights (or scope) is not identical to the barrel/bore axis.

Homicide in a Horse Barn?

As forensic scientists and physicians, forensic pathologists are duty-bound to perform their examinations with integrity and professionalism. The practice of medicine requires knowledge regarding the history and presentation of the patient. In forensic pathology, the history includes scene and other investigative information, and the decedent's medical and social history. Such information is important for the correct certification of the cause and manner of death. Herein, the authors present a case originally thought by police and death investigators to represent a sexual-assault-related homicide, as an elderly female's body was found partially nude, and apparently beaten, on the muddy floor of her horse barn. At autopsy, some of the injuries were determined to be postmortem and caused by horses. Additionally, gastric Wishnewsky spots indicated hypothermia as a probable mechanism of death. Finally, an acute hip fracture was identified, which explained why she was incapable of moving from her potentially dangerous environment.

Multiple Symmetric Lipomatosis.

A significant number of medicolegal deaths involve ethanol. Deaths may be related to the acute, intoxicating effects of ethanol, either in decedents or within persons responsible for causing the deaths of others. Additionally, deaths may be related to chronic alcoholism. A chronic alcoholic may display characteristic external features which allow an observer, such as a forensic pathologist or other physician, to conclude that he/she is probably an alcoholic. Herein, the authors report two decedents with a rare condition known as "multiple symmetric lipomatosis" (MSL), which has a strong correlation with chronic alcoholism. Identification of the peculiar features associated with MSL should prompt the forensic pathologist to consider chronic alcoholism as a probable diagnosis.

Recreational Sporting Activity Vehicle-Related Deaths.

Deaths occurring in the setting of nonprofessional, vehicle-related, recreational sporting activities occurring on land or in water during warm or winter months represent a diverse group of cases. These deaths tend to involve scenarios where the participants are purposefully attempting to enjoy themselves prior to experiencing sudden, catastrophic accidents resulting in lethal outcomes. Ultimately, many of the deaths are related to the high speed at which these vehicle-related activities normally occur. Three broad categories of factors may play contributory roles in death: human factors, vehicle factors, and environmental factors. A series of selected cases are presented, representing examples of varying activity types, involving motorized and nonmotorized vehicles, land and water activities, and warm weather and cold weather environments. For each case, the various human, vehicle and environmental factors believed to be contributory to the accident are considered, and strategies for prevention of these and similar deaths involving recreational sporting vehicles are presented.

Fatal Dragging Deaths with Soft Tissue and Bone Grinding Injuries.

The classic grinding/dragging cutaneous injury has a target-like appearance, often with postmortem features and possible associated underlying bone grinding trauma. It is important that forensic pathologists be able to recognize and identify such injuries. In this report, we present two cases of classic grinding/dragging injuries that resulted in death.

Tandem Bullet Homicide.

The phenomenon referred to as "tandem bullets" occurs when two (or more) projectiles are expelled from a firearm barrel in a single pull of the trigger. A "tandem gunshot wound" occurs when tandem bullets produce injuries. Several scenarios can occur, including the occurrence of multiple entrance wounds produced by separate tandem projectiles as well as a single entrance wound through which multiple tandem projectiles enter the body. We present a case of homicide by tandem bullets in which two tandem bullets entered a single entrance wound, with one projectile exiting the body and one remaining within the body. In addition, we review the topic of tandem projectiles and summarize other situations that may cause initial confusion when attempting to account for all gunshot wounds on the skin and projectiles as viewed on pre-autopsy imaging.

Suicide by Bomb, with Decapitation.

Suicide by explosion is rare outside of the context of terrorist activities. We present a case of a man with a history of explosives expertise who committed suicide by bomb/decapitation. The case serves to remind forensic pathologists of several important issues when presented with a case involving explosives, such as ensuring the safety of all those involved in the investigation and the importance of interagency cooperation. Potentially invaluable ancillary tests at autopsy include performing radiology, collecting trace evidence, retaining clothing, ensuring the positive identity of the decedent, and recognizing the importance of documenting injury types and patterns.

Accidental Trauma Mimicking Homicidal Violence.

Homicide investigations represent an important function of death investigators. Although recognizing nonobvious homicides is crucial, an equally important role involves the identification of cases that initially present as possible homicides, but are ultimately discovered to not represent homicides. Failure to recognize such cases results in wasted time, squandered resources, false allegations, and potential life-altering consequences. The authors review a series of cases wherein initial investigation suggested a possibility that the deaths represented homicides. By carefully considering additional information, including scene findings, history, and postmortem examination, each was determined to represent an accidental traumatic death. In addition to highlighting the importance of recognizing accidental traumatic deaths that initially present as homicides, the cases serve to highlight the fact that forensic pathology cannot be practiced without knowledge of appropriate ancillary information. Although guarding against cognitive bias is important in all forensic disciplines, including forensic pathology, access to vital case-related ancillary information is an essential component of practicing medicine as a forensic pathologist.