“A Switch In Time…”

….will not save you nine. A surefire way to trigger a request from the local vital statistics agency to amend a death certificate (DC) is to improperly enter time intervals in the “approximate interval: onset to death” column.  Amendment of a DC can be a time-consuming task for the busy clinician depending on the complexity of the patient’s medical condition and terminal clinical course. When read from top to bottom, time intervals should progressively increase  from most recent to farthest back in time, corresponding to the logical progression of complications of a given disease or condition listed next to it.


Now an end to your waiting with bated breath… the answers to the August 13, 2017 PPQ:

  1. False. Ethylene glycol (EG) will not be detected on routine in-hospital blood screens. It also will not be detected on alcohol (ethanol) screens. Rapid diagnosis and treatment of EG poisoning is critical but may be hindered by many things like incomplete or confounding history, non-specific lab results, early clinical presentation, or low index of clinical suspicion. EG fatalities related to missed or delayed diagnosis, both published and unpublished cases alike, are encountered by Medical/Examiner Coroner Offices 1.
  2. Many errors are present in the cause-of-death statement including illogical time intervals (the subject of this entry) and the inclusion of an injury-associated condition in a supposedly natural death.



  1. Armstrong EJ, Englehart DA, Jenkins AJ, Balraj EK. Homicidal ethylene glycol intoxication- a report of a case. Am J Forensic Med Pathol. 2006. June;27(2):151-55.


Be leery of the Query and for more tips on how to avoid errors on death certificates, consult Chapter 8 in the textbook Essentials In Death Reporting and Death Certification: Practical Applications for the Clinical Practitioner available on Amazon or for a direct link, click on: https://www.amazon.com/Essentials-Death-Reporting-Certification-Applications/dp/0998533408/ref=sr_1_1?ie=UTF8&qid=1488731535&sr=8-1&keywords=death+certification

Tune in next time for Practice Pearls!

“Thou Shall Not Tamper with Evidence!”- The Fifth Commandment of Death Reporting and Death Certification

Case Scenario: A 25 year-old man sustains multiple homicidal gunshot wounds to the chest and extremities. He fails to respond to emergent surgical intervention and is pronounced dead intra-operatively. Family and friends request to see the decedent. In preparation for the viewing and in an effort to prevent potential contact with bodily fluids, the surgical resident wipes blood and debris from the hands of the decedent.

Medicolegal evidence comes in many forms both seen and unseen. The decedent or decedent’s clothing can harbor foreign hairs and fibers, foreign DNA-containing bodily fluids, drug paraphernalia and residues, weapons, gunshot residue, bullets, and bullet fragments, to name a few. In homicidal deaths, this evidence will be collected, tested, and later presented in a court of law affecting decisions of guilt or innocence, freedom or imprisonment. Care must be taken to preserve any potential evidence in its original state and to initiate and maintain the chain of custody.  The hands in particular are potentially high-yield body regions for foreign material thus the importance of securing paper (not plastic) bags over the hands in order to contain and preserve any adherent material. Paper bags may have been placed on the hands (and sometimes feet) prior to arrival to the hospital and should not be removed. Of course, the urgent need to access the hands (or feet) for application of life-saving measures is priority.

In homicidal cases especially, a no-contact policy should be enforced to prevent unintentional or deliberate alteration of any on-body evidence. This may require the assistance of hospital security and/or local law enforcement officers.

And what about the other 4 Commandments you ask?

Thou shall:

  • Recognize deaths reportable to the Medical Examiner/Coroner
  • Leave therapeutic devices in place
  • Promptly and properly certify non-jurisdictional deaths
  • Recognize the benefits of the autopsy and make use of the expertise of the autopsy Pathologist in the formulation of the cause-of-death statement


You’ll find more information on these Commandments and meaning of evidentiary value in the textbook Essentials of Death Reporting and Death Certification-Practical Applications for the Clinical Practitioner available on Amazon.com.


Now, time out for a PPQ!

  1. Ethylene glycol will be detected on routine hospital blood and urine screen tests. True or False?
  2. Identify errors present in the following cause-of-death statement.
Part I.



A. Hospital-acquired pneumonia

Approximate interval: Onset to death

< 1 week

Due to (or as a consequence of):

B. C-6 quadriplegia


>  1 year

Due to (or as a consequence of):

C. Mucous plugging


>  1 month

Due to (or as a consequence of):

D. Cardiac failure


>  1 month

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




Stay tuned for your next dose of Practice Pearls!