The End Is Near! But That’s Just the Beginning: A view under the Retrospectroscope.

If hindsight were 20/20, there would be no need for Practice Pearls in 2020.

The Practice Pearls lessons of 2019 put clinician educators in the spotlight. They have the important responsibility of molding future physicians, especially those destined to practice in one of the Primary Care specialties, into not only diagnosticians and caregivers, but also stewards of public health in helping us live longer, smarter and healthier lives. 2019 saw another blow to the already floundering hospital autopsy rate with the handing down of a so-called burden reduction rule put forth by the Centers for Medicare and Medicaid Services (CMS) which in part called for the removal of the requirement for a hospital’s medical staff to attempt to secure autopsies in all cases of unusual deaths and of medical-legal and education interest (1). Not exactly a good thing for clinical resident education. Clinical educators must prepare these doctors-in-training to educate families about the benefits of the autopsy, to take advantage of the expertise of the pathologist in understanding disease processes, to know when and how to report a death to the Medical Examiner or Coroner, and to know how to properly complete a death certificate and why it makes a difference (2,3,4,5). Earlier exposure of these topics to medical students would further bolster the efforts of clinical educators.

Mortality trends in the United States have identified cardiovascular disease, accidental drug overdoses, suicidal injury in adolescents, fall-related injury in the elderly, birth defects, and pregnancy complications as top common causes of death based on cause-specific information listed by the Certifiers of death in the cause-of-death section of the death certificate (6). There is much room for improvement of mortality trends.

The following death certificate was not originally certified by the local Medical Examiner but by a clinician, not so auld lang syne, but in the not- so-distant past of the latter half of 2019:

There’s still work to be done….
Out with the old and in with more, so desperately needed, new pearls of clinical practice wisdom!

References:
1. Omnibus Burden Reduction (Conditions of Participation) Final Rule CMS-3346-F. Available at: https://www.cms.gov/newsroom/fact-sheets/omnibus-burden-reduction-conditions-participation-final-rule-cms-3346-f.
2. “How Trained is the Trainer-Comprehensive Medical Education: The Keystone of Modern Medicine”. Practice Pearls In Death Reporting and Death Certification, March 2019.
3. “Throwing mud at the wall: Sometimes it just doesn’t stick!”. Practice Pearls in Death Reporting and Death Certification, April 2019.
4. “Sch-o-o-o-ol’s-Out-For-the Summer!(But not if you’re a PGY-1 doc.)”. Practice Pearls in Death Reporting and Death Certification, July 2019.
5. “What Say You? Say It Isn’t So! Practice Pearls in Death Reporting and Death Certification”. October2019.
6. “Oh Say I-C-D!”. Practice Pearls in Death Reporting and Death Certification, May 2019.

 

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What Say You? Say It Isn’t So!

Attention Clinicians (and curious Georges and Georgettes) !

What do you tell families when their loved one has passed and the death has been reported to the Medical Examiner or Coroner (ME/C)?
Do you:
1. Tell the family that by law the ME/C must accept all deaths reported to them?
2. Do you say to the family that an autopsy will be performed because the ME/C is mandated by law to perform one on all reported and accepted deaths?
3. Do you say to them that an autopsy will be performed by the ME/C even when the ME/C has not taken jurisdiction over the death and their loved one will not be transported to the Office of the ME/C?

Because health care providers assume the answer to the above questions is ‘yes’, families of patients who have died at the hospital in which the death is reportable or has been reported are being told that an autopsy will automatically be done by the ME/C, because “it’s the law”. Then, when the family calls the ME/C to find out the results of the autopsy, they are surprised (and sometimes angry) to learn that an autopsy was not done.

The Medical Examiner or Coroner has jurisdictional authority (as mandated by state law) over sudden and unexpected deaths, violent deaths (suspected or obvious homicidal , suicidal, and accidental deaths), unattended deaths, deaths of unknown or uncertain causes, deaths in which a non-natural cause cannot be ruled out, and deaths of the unclaimed and unidentified. These are the reportable deaths and also include deaths occurring within 24 hours of admission or deaths occurring after several days or more of hospitalization from non-natural causes.

The ME/C will not automatically assume jurisdiction over all deaths originating from a medical facility, particularly those due to natural diseases and their complications, and those in which injury or the toxic effects of medications or drugs did not play a part. This would also include deaths in which there may have been a history of some type of remote injury not connected with the current death circumstances OR deaths in which there was a history of some type of recent injury followed by a return to baseline health in the setting of stable chronic natural disease with lethal potential, like certain heart or lung diseases.

Contrary to popular belief of those practicing clinical medicine and many others:
1. The ME/C will not assume jurisdiction over all deaths reported to them. The ME/C will not certify (meaning complete the death certificate on ) deaths for which jurisdiction was not taken. These are the deaths that resulted from natural disease and these are the ones that are certifiable by clinical practitioners BY LAW. 1,2
2. The ME/C will not have an autopsy done on every case for which jurisdiction has been taken. The decision to do an autopsy is made on a case-by-case basis. Even without an autopsy, an external examination of the body, review of medical and other records, and review of results of any postmortem testing are done. Determination of the cause and manner of death with completion of the death certificate will follow. A family, specifically the next-of-kin, may request an autopsy to be done and must do so in a timely manner . The honoring of that request is at the discretion of the ME/C.
3. The ME/C will not perform an autopsy on cases for which jurisdiction was NOT taken. This should be a no-brainer. Why would an ME/C do an autopsy on a non-ME/C case? For a hospital death, if the family (again next-of-kin to be specific) wants an autopsy done then the hospital pathologist would perform the autopsy at cost to the family unless the cost is waived by the hospital, especially at a teaching hospital. Otherwise families are on their own with the option to seek the assistance of a private autopsy service.

Medical Examiners’ and Coroners’ Offices are government agencies and have a very important public health-oriented mandate of timely cause and manner of death determination, funded by us taxpayers. They work with limited resources, staff, and budget strategically applied in order to meet that mandate which involves the investigation of approximately 500,000 deaths out of the approximately 1 million deaths reported per year 3,4.

References:
1. Information For Physicians Who Sign (Certify) Death Certificates . Available at : https://www.tn.gov/content/dam/tn/health/documents/BME_Note112105.pdf.
2. The Ohio Revised Code 3705-16. Statements in facts of certificates-death certificate. http://codes.ohio.gov/orc/3705.16.
3. Hickman MJ, Hughes KA, Strom KJ, and Ropero-Miller JD. Medical Examiners’ and Coroners’ Offices, 2004. Available at: www.bjs.gov/content/pub/pdf/meco04.pdf.
4. Armstrong EJ. 2017. Essentials of Death Reporting and Death Certification: Practical Applications for the Clinical Practitioner.

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Sch-o-o-o-ol’s-Out-for-the Summer! (But not if you’re a PGY-1 doc.)

(The following is a slightly refurbished reprise from a previously published oldie but goodie Practice Pearls -from way back in July 2018 entitled: Comprehensive Public Health Education for the Clinical Practitioner: Mission Impossible?)

The school bell has rung and school has been out to the glee of many except for the fresh-faced, eager resident physicians who have recently embarked on a brand new journey, the first post-graduate year, AKA PGY-1. Others have advanced onward to the years that follow as required by their chosen specialty.

Medical education provided to those destined for clinical practice emphasizes development of clinical skills for the diagnosis, treatment, and prevention of disease in the living. Public health-oriented topics including disease prevention, epidemiology, and systems-based practice are also part of the spectra of medical education. Resources for integrating public health education into all health professions abound creating challenges and opportunities for health professional schools to formulate comprehensive curricula within a defined period of time of students’ training (1,2). The clinician-in-training, especially those training in the primary care specialties, must also be taught the importance of mandated reporting of certain diseases and circumstances that may place the health or well-being of the patient or the immediate public in jeopardy. Mandatory reporting includes documentation of vital events and circumstances such as birth, abuse and neglect, impaired driving, work-related injury and communicable and other diseases (3). It is vitally important to the surveillance of public health and safety. The overall focus of public health education is on the living. Believe it or not, certain aspects of death actually aid the living.

The proper medical certification of death continues to be an important public health topic inadequately covered or lacking altogether in medical education. This is especially true for physicians, starting in medical school, where early introduction has been shown to be beneficial (4). Erroneous cause-of-death information has direct bearing on health statistics and resource allocation. Early introduction on the topic of death certification with periodic instruction and evaluation throughout and beyond medical training is needed to ensure that the most accurate cause-of-death information is entered on death certificates. For physicians-in-training especially, didactic teaching based on reference texts and e-learning tutorial platforms can be introduced into medical school curricula starting after a foundation in anatomy, physiology, pharmacology, pathology has been established and with the start of clinical rotations in the 3rd year (5). Clinical residency training programs should incorporate lectures into the curriculum with evaluation by way of in-service examinations, as effectiveness of this level of integration has been shown to be beneficial (6). Hospitals and medical societies should continue to provide lectures and tutorials for their clinical practitioners which can be counted as continuing medical educational credit (7).

Physician medical examiners and coroners are proficient in death certification and can be an invaluable educational resource for medical educators. Vital statistics professionals in each state are an added important educational resource for instruction especially in the technical aspects of death certificate completion including access to the electronic death registration system active in all but 2 states in the US (8) .

References:
1. Public Health and Medical Education Bibliography. Available at: https://www.aamc.org/download/258062/data/publichealthbibliography.pdf .
2. Integrating Public Health in Health Professions Education: A Resource for Students, Educators, and Health Professionals. Available at: https://www.cdc.gov/learning/local/pdf/ph-education-resource-list.pdf .
3. Reportable Diseases, Medline Plus. National Institutes of Health/US National Library of Medicine. Available at: https://medlineplus.gov/ency/article/001929.htm .
4. Degani AT, Patel RM, Smith BE, and Grimsley E. The effect of student training on accuracy of completion of death certificates. Med Educ Online. 2009;14:17. Available at: http://www.med-ed-online.org .
5. Armstrong EJ. Essentials of Death Reporting and Death Certification: Practical Applications for the Clinical Practitioner. Available at: https://www.amazon.com/Essentials-Death-Reporting-Certification-Applications/dp/0998533408 .
6. Henry CH, Greene CM, Koppaka R. Integrating public health-oriented e-learning into graduate medical education. Am J Public Health. 2012;102:s353-s356.
7. Massachusetts Medical Society. Cause of Death Training for Medical Certifiers. Available at: http://www.massmed.org/Continuing-Education-and-Events/Online-CME/Courses/Cause-of-Death-Training-for-Medical-Certifiers/Cause-of-Death-Training-for–Medical-Certifiers/ .
8. Information Systems for Vital Records Stewardship. National Association of Public Health Statistics and Information Systems. (NAPHSIS). Available at: https://www.naphsis.org/systems .

Be in-the-know with Practice Pearls…Because who really wants to get schooled?

 

For more information on how not to get schooled on reporting and certifying deaths, check out:

 

 

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Oh Say I-C-D !

As certifiers and reviewers of death certificates, we pledge allegiance to the mortality stats. The International Classification of Disease, currently in its 11th revision, is the foundation upon which health, disease, and injury trends derived from statistical data can be compared locally, nationally, and internationally (1,2).

Some mortality trends in the U.S.:
• Cardiovascular disease, still the #1 cause of death (3)
• As a result of drug overdoses, unintentional (accidental) deaths now occupy the 3rd leading cause of death bumping chronic respiratory deaths to the 4th spot (3)
• Suicides are now the #2 cause of death, ages 10-19 years (4)
• Out of all injury-associated deaths, those resulting from accidental falls account for the majority of deaths affecting our elders (5)
• The uptrend of women dying during or shortly after pregnancy continues(6)
• Birth defects, still the leading cause of infant deaths (7)
• Fueled by the opioid crisis, the drug overdose death rates continue to soar (8, 9)

How do we come to know of these trends?

The following is from a real death certificate in which a terminal mechanism, common to many types of deaths, was listed as the cause of death:

 

 

Just so happens that there’s a code for that, but which one of the ICD codes below apply?
MC82 Cardiac arrest

MC82.0 Ventricular tachycardia and fibrillation cardiac arrest

MC82.1 Bradycardic cardiac arrest

MC82.2 Asystolic cardiac arrest

MC82.3 Cardiac arrest with pulseless electrical activity

MC82.4 Cardiopulmonary arrest

MC82.Z Cardiac arrest, unspecified

 

Maybe the real cause of death is somewhere under one of these categories:
ICD-11 – Mortality and Morbidity Statistics

01 Certain infectious or parasitic diseases

02 Neoplasms

03 Diseases of the blood or blood-forming organs

04 Diseases of the immune system

05 Endocrine, nutritional or metabolic diseases

06 Mental, behavioural or neurodevelopmental disorders

07 Sleep-wake disorders

08 Diseases of the nervous system

09 Diseases of the visual system

10 Diseases of the ear or mastoid process

11 Diseases of the circulatory system

12 Diseases of the respiratory system

13 Diseases of the digestive system

14 Diseases of the skin

15 Diseases of the musculoskeletal system or connective tissue

16 Diseases of the genitourinary system

17 Conditions related to sexual health

18 Pregnancy, childbirth or the puerperium

19 Certain conditions originating in the perinatal period

20 Developmental anomalies

21 Symptoms, signs or clinical findings, not elsewhere classified

22 Injury, poisoning or certain other consequences of external causes

23 External causes of morbidity or mortality

It’s clear WHO can code it.
The question is how to decode it?
Specificity, the spice of life.

References:
1. World Health Organization: Classifications. Available at: https://www.who.int/classifications/icd/en/
2. World Health Organization: ICD 11 For Morbidty and Mortality Statistics (ICD 11 MMS) 2018 Version. Available at: https://icd.who.int/browse11/l-m/en
3. Centers for Disease Control and Prevention: Leading causes of death. Available at: https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm
4. National Vital Statistics System Reports: Recent Increases in Injury Mortality Among Children and Adolescents Aged 10–19 Years in the United States: 1999–2016. Available at: https://www.cdc.gov/nchs/data/nvsr/nvsr67/nvsr67_04.pdf
5. Burns E. Deaths from Falls Among Persons Aged ≥65 Years — United States, 2007–2016. Morbidity and Mortality Weekly Report. Available at: https://www.cdc.gov/mmwr/volumes/67/wr/mm6718a1.htm
6. Centers for Disease Control and Prevention. Pregnancy Mortality Surveillance System: Trends In Pregnancy-Related Deaths. Available at: https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pregnancy-mortality-surveillance-system.htm
7. National Vital Statistics System Reprts. Drugs Most Frequently Involved in Drug Overdose Deaths: United States, 2011–2016. Available at: https://www.cdc.gov/nchs/data/nvsr/nvsr67/nvsr67_09-508.pdf
8. Center for Disease Control and Prevention. Infant Mortality. Available at: https://www.cdc.gov/reproductivehealth/maternalinfanthealth/infantmortality.htm
9. Centers for Disease Control and Prevention. Drug Overdose Deaths. Available at: https://www.cdc.gov/drugoverdose/data/statedeaths.html

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Throwing mud at the wall: Sometimes it just doesn’t stick!

The following death certificate did not pass the Vital Statistics “sniff test” and was sent to the local Medical Examiner’s office for review and amendment:

By all appearances, the patient had a number of serious health conditions. But which one killed the patient? The heart disease, the diabetes or perhaps the congestive heart failure? Did the spinal abscess causing cord compression and paralysis stem from a remote injury and therefore this really isn’t a natural death as was checked off in the manner-of-death section? How does that cause congestive heart failure? If somehow the paralysis with heart failure are linked and are the main cause of death, why is it listed in Part II instead of Part I?

By simply listing all of the patient’s major medical conditions, the laundry-list, catch-all approach to certifying this death missed the mark of identifying the one disease entity that triggered a series of interrelated complications that over time ultimately led to the death. Which International Classification of Disease (ICD) code applies in this death? More than one is represented. There can only be one.

Buzzwords like paresis and paralysis are red flags for injury as the possible underling cause. Injury and its complications fall under the domain of the Medical Examiner or Coroner (i.e. they are reportable deaths). Following a medicolegal investigation into the death circumstances, deaths resulting from injury will be classified as accident, homicide, or suicide.

An important question regarding the manner in which the spinal abscess with paresis was acquired remains- Gunshot wound to the spine? Intravenous injection of drugs with a dirty needle? Spinal trauma from a fall or a jump? Complication of spinal surgery…for an injury or a birth defect? Complication of natural disease like diabetes? Trends derived from manner of death classification have far-reaching important public health implications (1) .

Reference:
1. National Vital Statistics System-Mortality Data. Available at: https://www.cdc.gov/nchs/nvss/deaths.htm.

More tips on de-mudifying the death certificate can be found in Chapter 8: The Clinician Certifier of Death from Essentials of Death Reporting and Death Certification: Practical Applications for the Clinical Practitioner available at: https://www.amazon.com/Essentials-Death-Reporting-Certification-Applications/dp/0998533408 .

 

How Trained is the Trainer? Comprehensive Medical Education: The Keystone of Modern Medicine

A major milestone and rite of passage for thousands of medical students is eminent or has recently come to pass. For the last 3 ½ years, they have successfully cleared many major educational hurdles. They have waited anxiously for the day to find out where the next chapter of life will unfold.

That day…is Match Day. After graduation, they will begin a rigorous period of training as residents, and continue the journey on to becoming our future physicians.

Our health and therefore quality of life depends upon competent medical care. How ready will our future doctors really be to care for us, during life and at death? This will depend on the strength of resident training programs, particularly in the primary specialties like internal medicine, family medicine, pediatrics, obstetrics/gynecology geriatrics, and emergency medicine. This will also depend on their educators, their trainers, who carry out the educational goals of the training program for that medical specialty. Trainers will expend enormous time and effort to teach the medical resident about patient care and how to diagnose and treat disease and injury with the goals of prolonging life, increasing the quality of life, and preventing death. Unfortunately, this leaves little opportunity to give in-depth instruction on an important end-of-life patient care duty: proper death reporting and certification. Death is a daily reality and an eventuality, even after the best of clinical efforts. But what we learn from death importantly can and does aid the living.

With the ever-dwindling rate of hospital autopsies created by the veil of better diagnostic tools (better scans, better tests, better and quicker results etc.), the enthusiasm of physicians to become educated on proper death certification also continues to decline, a sentiment that “rubs off” on impressionable trainees 1,2. Despite this, the autopsy remains the gold standard and the quality assurance tool for understanding disease processes and identifying the actual cause of the patient’s death 2.

But just how trained are the trainers? Are they prepared to educate doctors-in-training on how to:

  • educate families about the benefits of the autopsy and obtain consent for one 3 ?
  • utilize the expertise of the hospital pathologist and forensic pathologist to gain understanding of the lethal potential of disease as demonstrated by the autopsy 3 ?
  • locate and apply the legal statutes that mandate reporting certain deaths to the Medical Examiner or Coroner (ME/C) 3 ?
  • locate and apply the legal statutes that mandate the physician-of-record to certify deaths that do not fall under the jurisdiction of the ME/C 3 ?
  • access resources on death reporting and death certification provided by ME/Cs and local and state Vital Statistics agencies?
  • compose an acceptable and defensible cause-death-statement on the death certificate 3 ?
  • execute role as stewards of public health?

As part of a comprehensive curriculum, resident training programs must begin or continue to make routine efforts to increase proficiency in death reporting and death certification and include this as a core competency milestone requirement of graduate medical education in the primary care specialties 4. This is necessary in order to increase the accuracy of the information derived from death certificates such as the leading causes of death, disease patterns, and outcomes of the many types of medical intervention. It cannot be overstated that the cause of death information provided on death certificates directly influences mortality data, disease surveillance and fund allocation for health programs. Traditional lectures, morbidity and mortality conferences, and online courses and tutorials can be used as platforms of instruction throughout the years of clinical training and beyond. Demonstration of competency in death reporting and certification, just like for any medical procedure, should be required, not voluntary.

 

 

References:                                                                         

  1. Wexelman BA, Eden E, and Rose KM. Survey of New York City resident physicians on cause-of-death reporting, 2010. Prev Chronic Dis. 2013;10:E76. Available at: https://dx.doi.org/10.5888%2Fpcd10.120288 .
  2. Burton EC. The autopsy: a professional responsibility in assuring quality of care. Am J Med Qual. 2002. Mar-Apr; 17(2):56-60.
  3. Armstrong EJ. Essentials of Death Reporting and Death Certification: Practical Applications for the Clinical Practitioner Chapters 3, 5, 7 and 8. 2017. Available at: https://www.amazon.com/Essentials-Death-Reporting-Certification-Applications/dp/0998533408 .
  4. Accreditation Council for Graduate Medical Education (ACGME) Milestones Guidebook. Available at: https://www.acgme.org/Portals/0/MilestonesGuidebook.pdf .

 

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“When You Wish Upon a Stat…” Part II: To Err Is not to Error!

The following death certificates (DCs), completed by local physicians, were flagged by the local Vital Statistics and referred to the local Medical Examiner (ME) because they contained a number of errors.

Part I.                               

 

 

 

A.   Cardiopulmonary arrest

 

Approximate interval: Onset to death

 

Sudden

Due to (or as a consequence of):

B.

 

Due to (or as a consequence of):

C.

 

Due to (or as a consequence of):

 

D.

 

Part II. Other significant conditions contributing to death but not resulting in the underlying cause given in Part I

 

    COPD, Paraplegia

 

Manner of Death

 

Natural

 

  • Cardiopulmonary arrest: This is a non-specific, terminal, mechanistic event common to all deaths and should not be listed. More importantly, the specific etiology is omitted. Listing  of time-associated terms like seconds, minutes, hours, or days, with our without specific numbers in the time-interval column is permitted not vague terms like “sudden”.
  • COPD: Asthma? Emphysema? Bronchitis? Pneumonconiosis?
  • Paraplegia: If this is a complication of injury and also a contributing factor in the death, the manner of death cannot be natural. Clinicians certify deaths due to natural disease only. Injury-associated deaths must be reported to the ME or Coroner!

 

Part I.

 

 

 

A.   Respiratory failure, paraplegia      

Approximate interval: Onset to death

 

1-3 days

Due to (or as a consequence of):

 

B.    Dementia, neurogenic bladder

 

1-3 wks

Due to (or as a consequence of):

 

C.  Paraplegia, Stage IV sacral ulcer

 

1-4 months

Due to (or as a consequence of):

 

D.  Paraplegia, spinal meningeal tumor

 

1-3 years

Part II. Other significant conditions contributing to death but not resulting in the underlying cause given in Part I

 

Manner of Death

 

Natural

 

This DC is a laundry list of the patient’s current medical conditions, some unrelated, and is a classic example of what the DC is not intended for.

  • Respiratory failure, paraplegia: A non-specific mechanism is listed with a potentially unrelated, injury-associated condition. Another example of a death that should have been reported.
  • Lines ‘b’ and ‘c’ also list 2 conditions, one of which has competing conditions. Dementia has nothing to do with neurgenic bladder. Only one condition per line should be listed.
  • Paraplegia, spinal meningeal tumor: This suggests perhaps that the spinal meningeal tumor may have had something to do with the paraplegia. But it is not clear. When it is not clear or known whether the paraplegia was caused by injury versus a natural disease condition, the death must be reported to the ME or Coroner. It would be necessary to rule out (or in) accidental, homicidal, or suicidal injury as an underlying cause of the paraplegia or confirm that the spinal tumor was the cause. Moreover, the type (meningioma vs melanoma vs other), stage, and grade of the spinal tumor should be included if known.
  • Paraplegia, spinal meningeal tumor, Stage IV sacral ulcer, dementia, neurogenic bladder: Starting with line ‘a’, the place for the immediate cause of death, which is the last condition prior to death, and as read from top to bottom, there is no logical cause-and-effect relationship between these conditions. Respiratory failure and paraplegia are not caused by (or due to) dementia and neurogenic bladder. While neurogenic bladder may be due to paraplegia, Stage IV sacral ulcer is not. Stage IV (decubital) ulcers are often complications of paraplegia stemming from immobility and can also lead to bone infection (osteomyelitis) which in turn can lead to sepsis, multiorgan failure, and death. Was this part of the patient’s terminal course? The lack of cause-and-effect relationship will cause conflicting or overlapping time intervals to be listed. The time intervals, when read from top to bottom, should progressively increase in time. It is also improper to enter ranges of time as done on this DC. If the time intervals don’t make sense, then there’s a good chance that the corresponding conditions don’t either.

 

Part I.

 

 

 

 

D.     Possible arrhythmia         

 

Approximate interval: Onset to death

 

 

Few hours

Due to (or as a consequence of):

 

B.     Congestive heart failure

 

Due to (or as a consequence of):

C.

 

Due to (or as a consequence of):

D.

 

Part II. Other significant conditions contributing to death but not resulting in the underlying cause given in Part I

 

         CKD, Uncontrolled DM, Cocaine Abuse

 

Manner of Death

 

Natural

 

  • Possible arrhythmia: It is permissible to indicate uncertainty by use of the words “possible” or “probable” in the setting of absent or incomplete medical information. However, use of mechanistic terminology is unnecessary but if used, should be accompanied by a specific etiology. “Hours” or the specific number of hours (not ‘”few”) should be listed in the time interval column.

Congestive heart failure: Not much more specific that “possible arrhythmia”. What cause it? Natural disease ,intoxicant, or complication an injury? The approximate interval from onset to death is also erroneously omitted.

  • COCAINE Abuse: Stop the presses! Was current use (i.e. a positive urine drug screen) ruled out? With this drug possibly a factor in the death, (since the certifier listed it in Part II) the manner of death could change from natural to accidental, in the setting of recreational use and no evidence of suicidality or criminal poisoning. The death in this case should have been reported to the ME or Coroner. The acute and/or chronic effects of cocaine use would be confirmed based on results of postmortem testing and autopsy findings. With uncontrolled diabetes mellitus a factor (since the certifier listed it Part II), postmortem testing would also identify diabetic ketoacidosis, which by itself is a cause of death.
  • CKD, DM: While common medical abbreviations are recognized by vital statistics professionals and nosologists, overlap exists. Use of abbreviations should be avoided to prevent the need to guess intended meaning on the part of  the certifier.

From the identification of the specific types of drugs driving the current drug death crisis to identifying deaths associated with defective medical devices, to the ranking of the most common causes of death, we stay informed (1, 2, 3 ) .

The more accurate and error-free the “raw materials” provided by certifiers of death, the better informed we are and ultimately the better off we are healthwise (4).

References:

  1. Drug overdose death data. Centers for Disease Control and Prevention. Available at: https://www.cdc.gov/drugoverdose/data/statedeaths.html .
  2. Food and Drug Administration (FDA) Medical Products Program-MedWatch www.fda.gov/medwatch .
  3. Mortality in the United States, 2016. Centers for Disease Control and Prevention. Available at: https://www.cdc.gov/nchs/products/databriefs/db293.htm .
  4. . Armstrong E J. 2017. Death Certificate Errors. In Essentials of Death Reporting and Death Certification-Practical Applications for the Clinical Practitioner pp. 146-58.

“When You Wish Upon a Stat…”

these DCs will leave you flat!

The following are cause-of-death statements taken from actual death certificates (DCs) completed by local physicians, flagged by the local Vital Statistics for a number of glaring reasons. Can you identify them?

Part I.

 

 

 

A.    Cardiopulmonary arrest

 

Approximate interval: Onset to death

 

Sudden

Due to (or as a consequence of):

B.

Due to (or as a consequence of):

C.

Due to (or as a consequence of):

 

D.

Part II. Other significant conditions contributing to death but not resulting in the underlying cause given in Part I

 

COPD, Paraplegia

Manner of Death

 

Natural

 

Part I.

 

 

 

A.    Respiratory failure, paraplegia

Approximate interval: Onset to death

 

1-3 days

Due to (or as a consequence of):

 

B.    Dementia, neurogenic bladder

 

1-3 wks

Due to (or as a consequence of):

 

C.  Paraplegia, Stage IV sacral ulcer

 

1-4 months

Due to (or as a consequence of):

 

D.  Paraplegia, spinal meningeal tumor

 

1-3 years

Part II. Other significant conditions contributing to death but not resulting in the underlying cause given in Part I
Manner of Death

 

Natural

 

 

Part I.

 

 

 

 

A.  Possible arrhythmia

 

Approximate interval: Onset to death

 

 

Few hours

Due to (or as a consequence of):

 

B.     Congestive heart failure

Due to (or as a consequence of):

C.

Due to (or as a consequence of):

D.

Part II. Other significant conditions contributing to death but not resulting in the underlying cause given in Part I

 

CKD, Uncontrolled DM, Cocaine Abuse

Manner of Death

 

Natural

 

 

A great amount and variety of statistical information is derived from the classification of different causes of death providing clinical practitioners with foundational information upon which to improve medical diagnosis and optimize patient care. This is facilitated by the classification system known as the International Classification of Disease (ICD) currently in its 11th revision. Clinicians are also (painfully) aware of the related clinical modification coding system ICD-CM which applies codes to medical diagnoses for many purposes including the monitoring of disease rates, medical care review, and basic health statistics. From the identification of the specific types of drugs driving the current drug death crisis to identifying deaths associated with defective medical devices, to the ranking of the most common causes of death, we stay informed (1, 2, 3 ) .

The more accurate and error-free the “raw materials” provided by certifiers of death, the better informed we are and ultimately the better off we are health wise (4).

References:

  1. Drug overdose death data. Centers for Disease Control and Prevention. Available at: https://www.cdc.gov/drugoverdose/data/statedeaths.html .
  2. Food and Drug Administration (FDA) Medical Products Program-MedWatch www.fda.gov/medwatch .
  3. Mortality in the United States, 2016. Centers for Disease Control and Prevention. Available at: https://www.cdc.gov/nchs/products/databriefs/db293.htm .
  4. Armstrong E J. 2017. Death Certificate Errors. In Essentials of Death Reporting and Death Certification-Practical Applications for the Clinical Practitioner pp. 146-58.

Divisive Devices and Curious Cuts, Part II: Adventures In Medical Intervention and Other Eye Foolery.

The type, number, distribution, and pathologic effects of injuries seen at autopsy are clues that assist the forensic pathologist in the determination of the manner in which they were acquired whether by accident or at the hands of another. Accurate determination is of vital medicolegal importance with influence on the reconstruction of the death circumstances and any adjudication that may follow in the future.

Certain devices and types of medical intervention leave “injuries” recognized as those resulting from resuscitative efforts and surgical procedures. Unnecessary modification or distortion of injuries makes interpretation complicated. Context (i.e. medical records and EMS reports), is usually helpful and always needed in deciphering “injuries” caused by therapeutic intervention from other types of injury.

And so…

(Caution! Graphic images follow!)

 

Classic patterned abrasions from a mechanical chest compression device, not the bottom of someone’s shoe.

 

Two stab wound-looking injuries next to a thoracotomy incision? On closer examination, turns out that there were two intersecting incisions and ONE bona fide stab wound of the axillary region.

 

Stab wounds and gunshot wounds may present as convenient ports for tube placement or starting points for incisions. This spells NIGHTMARE for the forensic pathologist. Steering clear of the evidentiary wounds is much more preferred as shown below in which the thoracotomy incision was made (nicely)above and not through the nearby 2 stab wounds.

 

Fingernail markings resulting from jaw thrust maneuver and intubation attempt as part of resuscitation efforts, NOT strangulation injuries. Not overcalling these as strangulation injuries saves law enforcement a lot of investigative time and effort.

 

Marks left by suturing can look like stippling abrasions associated with intermediate-range gunshot wounds. Overcalling suture marks as stippling wounds (victim shot within 2-3 feet) could contradict witness statements or other physical evidence that victim was an innocent bystander or otherwise shot from a greater distance. Unsuspecting or uninformed expert consultants who review autopsy photographs in absence of pertinent information risk providing incorrect opinions in regards to the muzzle-to-target distance estimation.

Suturing of gunshot wounds may  confound the determination not only of an approximate muzzle-to-target distance (aka range-of-fire) but also distort characteristics that help identify it as an entrance wound:

It is much more preferred that gunshot wounds of expired patients NOT be sutured or wiped but instead be preserved with bandaging or other wound occluding (but not wound mutilating) material placed and secured over the wound:

And finally, the classic rib spreader laceration ( skin tear) caused by the gear mechanism of the rib spreader device, is virtually always seen in conjunction with thoracotomy incisions so as not to be confused with inflicted injury.

 

 

References:

  1. Armstrong E J. 2017. Therapeutic Devices. In Essentials of Death Reporting and Death Certification-Practical Applications for the Clinical Practitioner p 27.
  2. Armstrong E J. 2017. Injury Types: A Primer for Clinical Practitioners. In Essentials of Death Reporting and Death Certification-Practical Applications for the Clinical Practitioner. pp 82-102.
  3. Harm T and Rajs J. Face and neck injuries due to resuscitation versus throttling. 1983. Forensic Sci Int. 1983;23:109-116.

Divisive Devices and Curious Cuts, Part I: Think Zebras when you hear hoof beats!


Forensic pathologists are regularly called upon to identify and characterize injuries. The accuracy of doing so can have a direct effect on the direction of an investigation conducted by law enforcement in cases where foul play is suspected to be involved in the death. Accurate interpretation of injuries can also have effects on the adjudication process down the line.

Determination of the cause of marks left by medical intervention can be extra challenging without the proper context 1,2,3.

The following images illustrate common quandaries in forensic pathology practice. (Warning! Graphic images follow!):

 

  

Stomped?                                                                           Stabbed twice?

                              

Strangled?                                                       Intermediate range gunshot wound?

Cut?

 

References:

  1. Armstrong E J. 2017. Therapeutic Devices. In Essentials of Death Reporting and Death Certification-Practical Applications for the Clinical Practitioner p 27.
  2. Armstrong E J. 2017. Injury Types: A Primer for Clinical Practitioners. In Essentials of Death Reporting and Death Certification-Practical Applications for the Clinical Practitioner. pp 82-102.
  3. Harm T and Rajs J. Face and neck injuries due to resuscitation versus throttling. 1983. Forensic Sci Int. 1983;23:109-116.