…before it’s too late.
On occasion and all too often, forensic pathologists encounter non-accidental traumatic deaths of the young, particularly older infants and young children. In a number of those tragic deaths, a history of injuries that are unexplained or accompanied by inconsistent “stories” as to what caused them is found. Autopsies often reveal blunt force trauma in various stages of healing, from recent bruising or internal bleeding to healing fractures to healed scars on atypical body regions, indicating that the injuries were inflicted at different times 1, 2 . Furthermore, the pattern and location of the injuries are found to be inconsistent with either the developmental stage or typical accidental–type injuries 1, 2 . Review of medical records sometimes reveals that the infant or child had been medically evaluated for “mysterious” injuries or some other ailment that required at least a physical examination if not additional diagnostic work-up. Despite being presented with physical findings that should have prompted concern and action, the suspicion of physical abuse (or physical injury stemming from neglect) was not reported. In other instances, physical findings were missed altogether thus precluding reporting.
Among other professionals, clinicians that treat infants and children whether in the emergency room or in the clinic, are in a unique position to intervene in cases of suspected abuse and neglect by promptly taking the steps to report any reasonable suspicion knowing that certain statutory legal protections exist for them 3 . Steps will (or should) then be promptly taken by child welfare professionals to protect that child and any other child that may be in the home. These steps are vitally important requiring coordinated efforts that also can involve multiple other agencies including law enforecement. A breakdown in any point of the “system” can and has led to tragedy 4, 5 . Clinical medical education ensures a heightened awareness of the sentinel signs of abuse and neglect 6, 7.
Through practice in their respective fields, clinicians and forensic pathologists alike continue to play a critical role in quality assurance and improvement of patient care and public health 8 .
- Kepron C, Walker A, Milroy C. Are there hallmarks of child abuse? II. Non-osseous injuries. Acad Forensic. Pathol.. Dec. 2016. Available at: http://journals.sagepub.com/doi/pdf/10.23907/2016.057 .
- Walker A, Kepron C, Milroy C. Are there hallmarks of child abuse? I. Osseous injuries. Acad Foren. Pathol.. Dec. 2016. Available at: http://journals.sagepub.com/doi/full/10.23907/2016.056 .
- US Department of Health and Human Services-Child Welfare Information Gateway : Mandatory Reporters of Child Abuse and Neglect. Available at: https://www.childwelfare.gov/pubPDFs/manda.pdf .
- “Child abuse and neglect kills hundreds in view of authorities, AP reports”. Available at: https://www.cbsnews.com/news/child-abuse-neglect-kills-hundreds-in-view-of-authorities-ap-reports/ .
- Health and Human Services: Administration for Children and Families. “Within Our Reach: A National Strategy to Eliminate Child Abuse and Neglect Fatalities. Administration”. Available at: https://www.acf.hhs.gov/sites/default/files/cb/cecanf_final_report.pdf .
- Tiyyagura G, Beucher M, Bechtel K, et. al. Non-accidental injury in pediatric patients: detection evaluation, and treatment. Pediatric Emergency Medical Practice. Available at: https://www.med.unc.edu/pediatrics/specialties/emergency/uncpemportal/pem-library/child-abuse-nat/nonaccidental-injury-in-pediatric-patients-detection-evaluation-and-treatment .
- Christian C W. The evaluation of suspected child physical abuse. May 2015. Pediatrics:135(3). Available at: http://pediatrics.aappublications.org/content/135/5/e1337 .
- Armstrong EJ. 2017. Ch. 6-Forensic Pathology: The Forensic Pathologist’s Role in Quality Assurance and Improvement of Patient Care and Public Health. In 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 .
A miracle happened recently! A local Cleveland area hospital laboratory added fentanyl screening to their Urine Drug Screen panel! Good news for patient care in light of the following case scenario involving a death at another local hospital:
A 25-year-old man with a history of opiate (heroin) substance use disorder is found by a relative unresponsive and not breathing at home surrounded by drug paraphernalia. The relative reported that he had “snorted something” earlier. The man was found in cardiorespiratory arrest by paramedics and resuscitative efforts were begun and continued en route to the hospital. Intravenous fluids and doses of Narcan were given. A urine drug screen was negative. The man expired despite nearly 2 hours of resuscitative efforts. While a drug overdose was suspected, the exact cause of his death was unknown. The death was reported and accepted by the local Medical Examiner. An autopsy was performed. Hospital admissions samples were obtained for postmortem forensic toxicological testing which later revealed the presence of fentanyl.
Standard urine drug screens used by many hospitals do not include screening for fentanyl. It appears that this is finally slowly changing in response to the alarming death trends broadcasted in statistical reports generated by the Centers for Disease Control and Prevention and more locally by Medical Examiners’ and Coroners’ offices (1, 2,3, 4). Clinicians need to be cognizant of the scope and limitations of urine and blood drug screening tests used their hospital laboratories ( 5).
The opioid crisis is still raging shattering families and exacting a serious toll on medical first responders, police, social services, clinical practitioners, the non-medical workforce, and Medical Examiner’s and Coroner’s Offices. Novel, clandestinely manufactured, potent, and deadly fentanyl analogues continue to be discovered by forensic toxicology laboratories (6).
Next on Doc4N6’s Wish-List: the hospital Blood and Urine Fentalogue Screening Panel.
- Arditi L. As overdoses surge, many R.I. hospitals start testing for fentanyl in ERs. April 4, 2017. Providence Journal. Available at: http://www.providencejournal.com/news/20170404/as-overdoses-surge-many-ri-hospitals-start-testing-for-fentanyl-in-ers .
- Hedegaard H, Warner M, Minino A. Drug Overdose Deaths in the United States 199-2016. December 2017. NCHS Data Brief. No. 294. Available at: https://www.cdc.gov/nchs/data/databriefs/db294.pdf .
- Heroin/Fentanyl/Cocaine-Related Deaths in Cuyahoga County 2017. Available at: http://medicalexaminer.cuyahogacounty.us/pdf_medicalexaminer/en-US/HeroinFentanylReports/100517-HeroinFentanylCocaine-Sept2017.pdf.
- Waite K, Deeken A, Perch S, Kohler L. Carfentanil and current opioid trends in Summit County, Ohio. December 2017. Acad. Forensic Pathology. Available at: http://journals.sagepub.com/doi/pdf/10.23907/2017.053 .
- Hill J. The urine drug screen. Know thy limitations. February 2016. Available at: http://www.tamingthesru.com/blog/intern-diagnostics/uds-know-thy-limitations .
- National Drug Early Warning System (NDEWS) Special Report. Fentanyl and Fentanyl Analogues. December 2015. Available at: http://pub.lucidpress.com/NDEWSFentanyl/ .
Another Match Day has come to pass with a new academic training year on the horizon. By the end of years of training, will these future clinical practitioners, particularly those in the primary care specialties, be able to:
- Provide family-centered assistance in the end-of-life and afterlife decision-making process for the deceased?
- Educate families about the patient care quality assurance benefits of the medical autopsy?
- Obtain consent from the next-of-kin for a medical autopsy and be cognizant of religious restrictions and objections?
- Utilize the expertise of the hospital pathologist to gain understanding of clinicopathologic correlation and the lethal potential of disease?
- Identify deaths that need reporting to the Medical Examiner or Coroner?
- Identify the fundamental goals of the Medical Examiner and Coroner and how they intersect with clinical medicine?
- Properly certify a death in a timely manner and recognize that there are consequences for not doing so?
- Identify the importance and many uses of the death certificate?
- Realize the many important roles of the clinical practitioner including the role as a mandated reporter and as a public health steward?
Most importantly, have training programs made routine efforts to connect the trainee with the many available resources and put systems in place that check progress and identify deficiencies in all of the above (1,2,3 )?
Education and guidance regarding the practitioner’s role in end-of-life (palliative) care exists for some in medical school and residency with efforts towards the development of standardized curricula (4, 5 ). Continuing efforts are needed to improve the underdeveloped curricula regarding an additional important component of patient care-afterlife care.
- Armstrong E J. 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