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.

M.E. Does Not Stand for “Morgue Express”!

Why wasn’t an autopsy performed on my patient? -a not too infrequent question for the Medical Examiner or Coroner (ME/C). Contrary to popular belief of many in clinical practice, however, an autopsy will not be performed on every ME/C case.

Yearly, the cause and manner of death of approximately a half-million people is determined by medical examiners’ and coroners’ offices. But an autopsy will be performed on only a percentage of these in large part, to rule out (or rule in) that some type of acute injury, acute intoxication, or the sequela of injury or intoxication, actually caused or contributed to the death. Furthermore, it is beyond the capacity of many offices that are limited by staffing, infrastructure, budget, and the effects of the current opioid crisis, to perform an autopsy on every death. So in a death with a history of natural disease with lethal potential and no indications of foul play or trauma, a cause of death can be determined with the aid of an external-only examination of the body along with review of medical records and test results. Careful evaluation as to whether an autopsy is needed will be further applied to sudden infant and child deaths that include a natural disease history. Interpretation of postmortem testing is an added “tool in the toolbox” that is used. The cause of death can also be determined without an autopsy, in certain in-hospital deaths caused by accidental or suicidal trauma that have been well-documented clinically, where an autopsy likely would only confirm what was previously known clinically.

Well-staffed ME/C offices provide scientific and autopsy services for jurisdictional deaths. Those deaths are sudden, unexpected, unexplained, or that may have arisen under circumstances other that natural: by accident, suicide, or homicide. Identifying a homicidal death, with the aid of an autopsy, is of high priority as this will start or continue the turning of the “wheels of justice”. ME/C offices provide a public service, from a fund of ever-diminishing tax dollars.

 

Now, finally, the end to the 2-week, nail-biting suspense is near! The answers to the last PPQ follows.

  1. False. “MSOD due to sepsis” is an UN-acceptable cause-of-death statement. Two errors are represented: use abbreviations and use of non-specific clinical terminology ‘sepsis’ which does not specify the organism and the start of the chain of events that lead to the sepsis (i.e. sequela of trauma versus some natural disease entity)
  2. False. (the subject of this entry and the method to all this madness)
  3. A,B,C, and D. Yes, all of these deaths are reportable. A-death in custody. B-death within 24 hours of admission or the clinical definition of sudden death. C-if seizures can be linked to the remote head trauma, the manner of death will not be classified as natural. D-trauma-associated death or possibly therapy-associated.

Caveat for B: While this death is reportable to the ME/C, it is ABSOLUTELY a death that is certifiable by the pronouncing physician or the patient’s primary care physician who may be asked by the Medical Examiner or Coroner Investigator if he/she is willing to certify the death and complete the death certificate.

 

For more information on what “triage” means to the Medical Examiner of Coroner, consult Chapters 5 and 6 in Essentials of Death Reporting and Death Certification: Practical Applications for the Clinical Practitioner available on Amazon.com.

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

 

Stay tuned for your next fix of Practice Pearls!