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!

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