Death By A Thousand…..and One Cuts?: The Therapy vs. Trauma Dilemma.

Most importantly, the urgency of a patient’s deteriorating clinical condition dictates rapid application of any and all life-saving measures. Furthermore, hospital deaths resulting from injury, particularly those arising from homicidal violence will fall under the jurisdiction of the Medical Examiner or Coroner and a medicolegal investigation into the death circumstances will follow. For the forensic pathologist, the specter of future court proceedings regarding any death is ever present. For the clinician, the specter of future court proceedings regarding a living patient who has sustained injury is also ever present; ergo the importance of injury documentation and interpretation.

Interpretation of the number, type, pattern, and extent of external and internal injury is commonly performed by forensic pathologists and is a high priority in deaths resulting from homicidal violence. Injury interpretation may be made more difficult or impossible due to the confounding artifacts of therapeutic intervention.  The medical record may not accurately reflect or describe all interventions and it may be necessary for the forensic pathologist to contact the treating physician prior to commencing an autopsy. ACLS run sheets, anesthesia records, and operative notes are VERY useful to the forensic pathologist and can be helpful in deciphering inflicted versus therapy-associated injury but these records are not always immediately available. Injuries caused by mechanical chest compressors and rib spreaders are pretty characteristic and always come with a clinical context. Mimickers of inflicted injury include chest tube incisions, incomplete/complete thoracotomy incisions, venipunctures, scalp monitors, cut-down procedures for vascular access and contused impressions left by cervical collars and blood pressure cuffs. Inflicted wounds like gunshot wounds and stab wounds may be used as access ports for placement of therapeutic devices such as chest tubes making interpretation difficult or impossible or otherwise confound the numeration of wounds. (The fact that entrance gunshot wounds may or may not have corresponding exit wounds and stab wounds can be either penetrating or perforating are well known to forensic pathologists.) Suturing of skin lacerations, gunshot wounds, and stab wounds will modify or obliterate certain identifying characteristics. Irrigation of skin wounds can wash away trace evidence. These procedures are necessary treatment and/or life-saving measures but should the patient expire, further manipulation of wounds must be avoided.

To assist forensic pathologists in the accurate interpretation of injuries:

  • make liberal use of the body diagram often included in medical charts
  • refrain from using stab wounds and gunshot wounds as access ports and if at all possible, do not incorporate them into a surgical incision
  • bandaging is much more preferable to suturing of wounds of patients pronounced dead on or just after arrival
  • leave all therapeutic devices in place
  • communicate with the medicolegal death investigator or better, the forensic pathologist who will perform the autopsy

You’ll find more information on the importance of injury recognition and preservation of trace evidence in Chapters 5 and 6 in Essentials of Death Reporting and Death Certification-Practical Applications for the Clinical Practitioner available on Amazon.com .

Now, test your comprehension and knowledge with a short PPQ:

  1. “MSOD due to sepsis” is an acceptable cause-of-death statement”. True or False?
  2. All hospital deaths that become Medical Examiner or Coroner’s cases will have an autopsy performed. True or False?
  3. Which of the following deaths is/are reportable to the Medical Examiner of Coroner?

A. 55 year-old man with a history of Bipolar Disorder and poorly-controlled diabetes found unresponsive in his jail cell. Pronounced 10 minutes after arrival to the hospital despite resuscitative efforts.

B. A 72 year-old woman with end-stage lung disease from chronic tobacco smoking, on home oxygen and with multiple prior admissions for pneumonia and acute respiratory failure. Found not breathing but with a pulse. Pronounced dead 16 hours after arrival to the hospital despite resuscitative efforts.

C. A 28 year-old man with a remote history of head trauma who presents to the emergency room with intractable seizures and subsequent cardiopulmonary arrest. He dies despite resuscitative efforts.

D. 78 year-old woman with a history of coronary artery disease and stent placements found without vital signs in the post-anesthesia recovery unit following repair of a hip fracture sustained in a mechanical fall.

Answers to this PPQ will appear in the next post.

Stay tuned for your next dose of Practice Pearls!

Alphabet Soup

The answer to the PPQ (Practice Pearls Quizlet) will be revealed. But first things first.

A surefire way to trigger a query from vital statistics officials is to commit one of several errors. One error is the use of medical abbreviations or acronyms and shorthand in the cause-of-death statement. Medical abbreviations while convenient are not necessarily universally understood by others less familiar with their many contextual meanings. So one way to avoid the inconvenience of the query, is to avoid the use of abbreviations, acronyms, and shorthand.

Consider the following possible translations for common medical abbreviations:

AMI: Acute Myocardial Infarct(-ion), Acute Mesenteric Ischemia

CHD: Coronary Heart Disease, Congenital Heart Disease, Chronic (Ischemic) Heart Disease

HLD: Hyperlipidemia, Hypersensitivity Lung Disease, Herniated Lumbar Disc

PE: Pulmonary Embolism, Pre-Eclampsia, Pleural Effusion

TAH: Total Abdominal Hysterectomy, Transfusion Associated Hepatitis

Each one of these conditions, if listed as the underlying cause of death, would be coded differently by nosologists, ultimately affecting mortality statistics. Many of them represent conditions with lethal potential. Others are not necessarily lethal if well-controlled or resolved.  Many of them also lack etiologic specificity and would not be appropriate to list as an underlying cause of death. Some of them may be associated with non-natural underlying causes which would require reporting to the Medical Examiner or Coroner. Still others may or may not be clinically significant enough to be listed in Part II. Indeed, nosologists are medical classification specialists, but they are not mind readers and they are not physicians.

…and not to omit: DVT– can’t quibble much with this one; Deep Vein Thrombosis especially in conjunction with Pulmonary Embolism or more specifically Pulmonary Arterial Thromboembolism would be the obvious choice. CHF– most would interpret as Congestive Heart Failure but Congenital Hepatic Fibrosis could apply in the right clinical context. Not much room to misinterpret NIDDM and CABG.

***And finally, the answer/explanation to the Inaugural PPQ from May 21st is: FALSE. Abbreviations are not acceptable.***

To illustrate, the sample presented in May 21st’s PPQ could be translated as:

Part I.

 

A. Pre-eclampsia/Deep Vein Thrombosis

Approximate interval: Onset to death

Days

Due to (or as a consequence of):

B. Acute Mesenteric Ischemia with Congenital Hepatic Fibrosis

 

Years

Due to (or as a consequence of):

C. Congenital Heart Disease

 

Years

Due to (or as a consequence of):

D. Hypersensitivity Lung Disease

 

Years

Part II. Other significant conditions contributing to death but not resulting in the underlying cause given in Part I: Non-Insulin Dependent Diabetes Mellitus, status post Coronary Artery Bypass Grafting times 3, status post Transfusion Associated Hepatitis
Manner of Death

Natural

 

Aside from the fact this statement makes absolutely no sense, additional errors happen to be represented and are also ones that should be avoided when formulating a cause of death.

Most likely, the intended translation was as follows:

Part I.

 

 

A. Pulmonary Embolism arising from Deep Venous Thrombosis

Approximate interval: Onset to death

Days

 

Due to (or as a consequence of):

B. Acute Myocardial Infarct with Congestive Heart Failure

 

*Years

Due to (or as a consequence of):

C. *Coronary Heart Disease

 

Years

Due to (or as a consequence of):

D. Hyperlipidemia

 

Years

Part II. Other significant conditions contributing to death but not resulting in the underlying cause given in Part I: Non-Insulin Dependent Diabetes Mellitus, status post Coronary Artery Bypass Grafting times 3, status post Total Abdominal Hysterectomy
Manner of Death

Natural

 

 

*Some tweaking of this statement may still be in order. For example, the time interval for line ‘b.’ makes more medical sense as “days” rather than “years”. For line ‘c’, Coronary Artery Disease or Atherosclerotic Coronary Artery Disease would be more specific. Finally, inclusion of Total Abdominal Hysterectomy in Part II is unnecessary.

For more examples of disastrous cause-of-death statements and how to avoid being caught in a query quagmire, consult Chapters 3 and 8 and take the Self-Assessment Test found in Essentials of Death Reporting and Death Certification-Practical Applications for the Clinical Practitioner available on Amazon.com .

For a direct link to this book, click on: https://www.amazon.com/Essentials-Death-Reporting-Certification-Applications/dp/0998533408/ref=sr_1_1?ie=UTF8&qid=1

 

Stay tuned for future PPQs and your next dose of Practice Pearls!