Chemical Warfare on the Mind and Body.

Think about it. Could the current epidemic of drug deaths represent a kind of chemical warfare, where the weapon is the drug and the mechanism is the addiction? A veritable army consisting of 63,632 persons in the US died from drug overdose in 2016 1. Recently, half of the country has seen a significant increase in the rate of overdose deaths, largely driven by opioids (especially heroin, fentanyl and other synthetic opioids) but more recently with a new twist-a resurgence of drug deaths that include stimulants, particularly cocaine and methamphetamine (2, 3, and Fig. 1).

 

Fig. 1: Statistically significant drug overdose death rate increase from 2015-2016, US states Available at: https://www.cdc.gov/drugoverdose/data/statedeaths.html

The causalities are in the prime of their life, able-bodied men and women in their 20’s to 40’s, and come from not just the demographic you think, but from all demographic and socioeconomic strata. Heroin addicts over the age of 55 years who have “managed” their addiction over the preceding decades with their usual supply of heroin, have been getting caught in the crossfire of the opioid epidemic, unknowingly consuming and dying from more potent heroin, heroin mixed with fentanyl, pure fentanyl, or fentanyl-like substances 4.

Is it intentional? Could there be a grand insidious scheme to do away with a population? The thought is disconcerting. Clever “marketing” easily lures those looking for the quick fix, the magic pill, the feeling of belonging, or a better way to cope with the stresses of life. On the other hand, addiction drives demand and demand drives the big profits made by clandestine drug labs 5. Clandestinely manufactured drugs (synthetic drugs) invade from within and outside a country’s borders by land, by sea, by air, underground, and by mail via online transactions 6,7,8. They are being made increasingly more potent and therefore potentially more deadly, and always a step or two ahead of the regulatory laws in places that have them.

Forensic toxicology laboratories struggle to keep up with the barrage of new “products” but must since the detection of each new drug is what keeps the wheels of justice turning, which is what the public expects and demands. In order to optimize patient care and the prevent deaths, hospital labs must also “keep up with the times” in regards to their ability to detect novel synthetic drugs 9.

Jails, hospitals, foodbanks, crisis hotlines, and other social safety nets are being taxed to their limits by those battling addiction or by their dependents left financially and emotionally bereft after the battle has been lost through death 10.

A country continues to loose individuals who would otherwise be contributing members of society through their intellectual and/or physical abilities 11. Anecdotes of the difficulties with finding drug-free workers should be warnings to be heeded and defining the scope of the actual toll on the workforce and the economy will require continued and vigilant study 12, 13.

Through periodic statistical reports and public media alerts regarding drug trends, Medical Examiners and Coroners (ME/C) are part of the army helping to fight the chemical war. Uniformity amongst ME/C offices in reporting specific drugs on death certificates is imperative 14, 15. Through diagnosis, treatment, prevention, and proper reporting of drug-related deaths, clinicians too play a vital role as combatants in the fight to save lives 16.

 

References:

  1. US drug overdose deaths continue to rise; increase fueled by synthetic opioids. Press release: March 29, 2018. Centers for Disease Control and Prevention. Available at: https://www.cdc.gov/media/releases/2018/p0329-drug-overdose-deaths.html .
  2. Drug overdose death data. Centers for Disease Control and Prevention. Available at: https://www.cdc.gov/drugoverdose/data/statedeaths.html .
  3. New surge of meth, cocaine mixed with powerful opioid pushes Ohio’s drug overdose death toll higher. April 2, 2018. Akron Beacon Journal/Ohio.com. Available at: https://www.ohio.com/akron/news/breaking-news-news/new-surge-of-meth-cocaine-mixed-with-powerful-opioid-pushes-ohios-drug-overdose-death-toll-higher .
  4. Opioid overdose deaths by age group. Available at: https://www.kff.org/other/state-indicator/opioid-overdose-deaths-by-age-group/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D .
  5. Understanding Clandestine Synthetic Drugs. Available at: https://www.unodc.org/pdf/report_2001-06-26_1/analysis_clandestine.pdf .
  6. Buxton J Bingham T. The Rise and Challenge of the Dark Net Drug Markets. Global Drug Policy Observatory Policy Brief. Jan 2015. Available at: https://idhdp.com/media/400190/darknet-20markets.pdf .
  7. Over and Under. USA Today. Available at: https://www.usatoday.com/border-wall/story/drug-trafficking-smuggling-cartels-tunnels/559814001/ .
  8. Fighting the Opioid Scourge. Department of Homeland Security-US Customs and Border Protection. Available at: https://www.cbp.gov/frontline/fighting-opioid-scourge .
  9. Tufel G. Continuing the Battle Against Drugs of Abuse. Clinical Lab Products. June 25, 2015. Available at: http://www.clpmag.com/2015/06/continuing-battle-drugs-abuse/ .
  10. Karsala M. The opioid epidemic and its impact on the health care system. The Hospitalist. October 24, 2017. Available at: https://www.the-hospitalist.org/hospitalist/article/149858/mental-health/opioid-epidemic-and-its-impact-health-care-system/page/0/1 .
  11. Valentic S. Workplace Drug Overdoses is Driving Need for Action. EHS Today. August 13. 2018. Available at: https://www.ehstoday.com/health/workplace-drug-overdoses-drive-need-action .
  12. Schwartz ND. Economy Needs Workers, but Drug Tests Take a Toll. New York Times, July 24, 2017. Available at: https://www.nytimes.com/2017/07/24/business/economy/drug-test-labor-hiring.html .
  13. Aliprantis D and Chen A. The Opioid Epidemic and the Labor Market. Economic Commentary. Sept. 29, 2017. Available at: https://www.clevelandfed.org/newsroom-and-events/publications/economic-commentary/2017-economic-commentaries/ec-201715-opioids.aspx .
  14. Slavova S, O’brien D, Creppage K, et. al. Drug Overdose Deaths-Let’s Get Specific. Public Health Report. July-Aug. 2015. Vol. 130. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4547584/pdf/phr130000339.pdf .
  15. Harper J. Omission on Death Certificates Lead to Undercounting of Opioid Overdoses. National Public Radio. Shots Health News Series. March 22, 2018. Available at: https://www.npr.org/sections/health-shots/2018/03/22/595787272/omissions-on-death-certificates-lead-to-undercounting-of-opioid-overdoses .
  16. Szalavitz M. Opioid Overdose: Emergency Treatment Is Crucial, but It’s Not Enough. Scientific American. May 13, 2016. Available at: https://blogs.scientificamerican.com/guest-blog/opioid-overdose-emergency-treatment-is-crucial-but-it-s-not-enough/ .

Body of Evidence Part III: Just Brown Baggin’ It.

There seems to be some lingering confusion among some hospital medical personnel and those involved with the recovery of human tissue and organs on the proper way to preserve potential evidence on the hands of patients who have died in the hospital as a result suspected foul play or outright homicidal violence. Recently, tissue procurement technicians placed plastic bags on the hands of a decedent who was destined to be transported to the local medical examiner’s office due to death circumstances highly suspicious for foul play.

Plastic bags, latex or nitrile gloves should NEVER be placed hands of a decedent that is a Medical Examiner’s or Coroner’s case. Because of their impermeability, unlike paper, they will contain condensation produced by the body’s heat prior to cooling. This condensation can promote the growth of bacteria and mold that can interfere with or preclude the recovery of foreign materials, i.e. the perpetrator’s DNA or the gunshot residue from the shooter’s gun.

PAPER not plastic please! A paper bag placed over each hand secured at the wrist by a rubber band is modus operandi! Better, forensically speaking (as well as more environmentally friendly).

Sometimes visuals are better memory aids:

     

YES!                                                                 NO!

       

NO!                                                     MAYBE.

 

(Only those of you who grew up in the 70’s watching the Gong Show will understand the last one.)

 

Your memory aide and ticket to more CME credits available at: https://www.amazon.com/Essentials-Death-Reporting-Certification-Applications/dp/0998533408 .

 

Reporting for Duty Part II: The Buck Stops Here!

It’s worth emphasizing that the major goal of medicolegal death investigation is to ensure that accidental, homicidal and suicidal deaths don’t get missed. In that effort, medical examiners and coroners are the bellwether for public health and safety. As an added benefit, this system of monitoring deaths also serves to document disease outbreaks and the extent and unexpected outcomes of chronic natural disease, especially undiagnosed or misdiagnosed natural disease conditions. Mortality data from death certificates generated by medical examiners’ and coroners’ offices complements that generated by those in clinical practice who certify the deaths of patients with well-documented natural disease conditions. Recognizing the lethal potential of many natural disease conditions, treated or not, will help to dispel the uncertainty many clinicians have when faced with certifying the deaths that result and reduce the knee-jerk tendency to “pass the buck” by reporting the death to the medical examiner/coroner (ME/C).

Time out for the answers to the last PPQ exercise.

Playing the role of the treating clinician of record, consider the following case scenarios and whether or not the circumstances dictate reporting:

  1. Sudden death in the ED in a 23 year-old female presenting with symptoms and signs of hypovolemic shock, electrolyte disturbance, and acute renal failure. Past medical history only of Addison’s disease, non-compliant with her prescribed medication regimen with multiple prior ER visits according to the EMR.

This death needs reporting. True or False?

False. This is an example of sudden death from a natural disease with known lethal potential that would be accelerated by not taking medication as prescribed. “Addisonian crisis with clinicopathologic sequela” is an example of a righteous cause of death that can be listed on the death certificate. Inclusion of terminology such as “non-compliance” is accusatory, unnecessary, and should not be included on a death certificate.

 

  1. Patient pronounced dead after arrival. History of ischemic cardiomyopathy and coronary artery disease with multiple prior admissions for acute exacerbation.

This death needs reporting. True or False?

False. This is an example of natural (chronic) disease with the potential for sudden death. As long as there no history of drug abuse, especially of stimulant types, this death is certifiable by the pronouncing physician or the physician responsible for the patient’s regular care. And yes, one CAN opine what the cause of the death is in this scenario without needing a clinical lab test to tell you so. Cause of death: “Atherosclerotic coronary artery disease with ischemic cardiomyopathy”.

 

  1. Sudden death in an asthmatic presenting in status asthmaticus with a history of cocaine abuse.

This death needs reporting. True or False?

True. There is a history of cocaine abuse. Chronic cocaine abuse by smoking is a recognized cause of the asthma variant of COPD and doing so can trigger an asthma attack at any time. It must be established whether or not cocaine contributed to or directly caused the status asthmaticus through postmortem analysis of blood by the forensic laboratory. If so, then the death is not purely due to natural causes which has implications for manner of death classification (ex. Accident). Clinicians do not certify accidental or other non-natural deaths.

 

  1. Death from bacterial sepsis following spontaneous perforation of ischemic bowel. Remote history of a gunshot wound to the abdomen with visceral injury complicated by bowel adhesions with incarceration requiring multiple abdominal surgeries.

This death needs reporting. True or False?

True. You’ve got gunshot wound in the history mix and the complications could have arisen from it. An automatic ME/C’s case. If you missed that one, shame on you! Unfortunately though, sometimes the little minor detail of the history of a gunshot wound gets lost and left out of the medical records generated over the years of treating the complications of the GSW which in and of themselves can be distinct natural disease entities.

 

  1. Sudden death in a patient visiting from another state, pronounced dead after 36 hours of hospitalization following resuscitative efforts for a respiratory arrest. Accordingly, no electronic medical record exists and the past medical history is otherwise unknown. A prescription for albuterol, metoprolol, atorvastatin, and methadone along with a DAWN kit are found among the patient’s personal effects. The UDS is negative.

This death needs reporting. True or False?

True. Most of the meds are for natural disease problems, like probably asthma, high blood pressure, and high cholesterol. But the methadone and DAWN kit is cause for pause. Maybe methadone was prescribed for chronic pain, but paired with the DAWN kit, more than likely there is a history of opioid abuse. What’s a DAWN kit anyway? Maybe you already know or otherwise for the curious or uninformed, google “DAWN kit”. And another thing, in the context of this scenario, a negative UDS does not mean that drugs were not used prior to death, especially if the hospital’s lab does not test for the many different types of opioids like fentanyl and fentanyl-related substances (aka fentalogues). For more on UDS, see July 30, 2017 installment “UDS-Universal Drug Screen?” at: https://deathreportingandcertification.info/2017/07/30/uds-universal-drug-screen/  

 

 

Like vitamins and minerals…get your copy at: https://www.amazon.com/Essentials-Death-Reporting-Certification-Applications/dp/0998533408

Reporting for Duty.

Knowing when to report a death requires clinicians to dutifully exercise some medical forethought. It requires the knowledge that while the phrase sudden death is the common thread that defines many reportable deaths, not all sudden deaths actually need reporting to the Medical Examiner or Coroner (ME/C) and can be certified by a treating clinician of record. It further requires the consideration that causes other than that due to natural disease could have triggered a chain of clinicopathologic events leading to the patient’s demise, be they sudden or delayed in progression.

Ultimately and for many important public health  and legal reasons, the goal is to ensure that deaths potentially occurring under non-natural circumstances are not missed and are otherwise identified, investigated, and certified by the ME/C.

Time out for a PPQ (Practice Pearls Quizlet) exercise. Playing the role of the treating clinician of record, consider the following case scenarios and whether or not the circumstances dictate reporting:

1. Sudden death in the ED in a 23 year-old female presenting with symptoms and signs of hypovolemic shock, electrolyte disturbance, and acute renal failure. Past medical history only of Addison’s disease, non-compliant with her prescribed medication regimen with multiple prior ER visits all nicely documented in the EMR.

This death needs reporting. True or False?

2. Patient pronounced dead after arrival. History of ischemic cardiomyopathy and coronary artery disease with multiple prior admissions for acute exacerbation.

This death needs reporting. True or False?

3. Sudden death in an asthmatic presenting in status asthmaticus with a history of cocaine abuse.

This death needs reporting. True or False?

4. Death from bacterial sepsis following spontaneous perforation of ischemic bowel. Remote history of a gunshot wound to the abdomen with visceral injury complicated by bowel adhesions with incarceration requiring multiple abdominal surgeries.

This death needs reporting. True or False?

5. Sudden death in a patient visiting from another state, pronounced dead after 36 hours of hospitalization following resuscitative efforts for a respiratory arrest. Accordingly, no electronic medical record exists and the past medical history is otherwise unknown. A prescription for albuterol, metoprolol, atorvastatin, and methadone along with a DAWN kit are found among the patient’s personal effects. The UDS is negative.

This death needs reporting. True or False?

 

A Manner of Fact.

How a death happened can be just as important as what caused the death. Yes, manner matters.

Take another look at the cause-of-death statement presented in the last installment of Practice Pearls. It was taken from an actual death certificate:

Part I.

 

 

 

A.                  Pneumonia-Aspiration poss.

 

Approximate interval: Onset to death

 

1 day

Due to (or as a consequence of):

 

B.                  Dysphagia

 

6 months

Due to (or as a consequence of):

 

C.                   Quadriplegia

 

3 years

Due to (or as a consequence of):

D.

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

Natural

 

While aspiration pneumonia could result from dysphagia which in turn could be caused by quadriplegia, the question that should linger in the certifier’s mind is: What is the cause of the quadriplegia? Cervical spinal cord damage by Multiple Sclerosis? Epidural abscess complicating cervical disc surgery? A fall with fracture of the cervical spine and injury to the spinal cord? Or perforating injury to the cervical spinal cord from a remote gunshot wound? The manner of death for each of the four scenarios is very different: Natural vs Therapeutic Complication vs. Accident vs. Homicide. If the death circumstances are or might be accidental, homicidal, therapy-associated 1 or anything not associated with pure natural disease, the death must be reported to the ME/C. If you are a clinician certifier and list ‘quadriplegia’ or other non-specific terms as the underlying cause of death (the lowest line in Part I), expect to be notified by your friendly local Vital Stats professional (or your patient’s funeral home)!

Clinicians certify only natural deaths. Medical Examiners and Coroner (ME/C) physicians certify ALL manners of death.

For clinicians, accurate cause and manner of death determination flows from clinical diagnoses, clinical terminal events, and knowledge of the lethal potential of disease 2. For physician ME/Cs, this flows from comprehensive medicolegal death investigation, from scene to autopsy.

For both clinicians and ME/Cs, cause and manner of death determinations summarized in the cause-of-death section on the death certificate have important wide-ranging public health ramifications including increasing overall awareness of certain death trends with aims at death prevention or reduction in mortality rates 3-10. Examples include:

  • Deaths associated with medical procedures and devices: reports and bulletins compiled from data provided by online reporting
  • Fall injury deaths: identifying medical risk factors and in-home hazards
  • Traffic accident deaths: identifying road hazards, intervention by law enforcement regarding distracted or impaired driving
  • Opioid deaths: identifying sources of clandestinely manufactured fentanyl analogues, prompting changes in clinician prescribing habits and promoting alternate treatments for acute and chronic pain
  • Accidental drowning deaths: promoting and instituting measures regarding pool safety and safe boating
  • Homicide deaths of intimate partners-prevention through education in conflict resolution, offender intervention, improvement of services for domestic violence victims
  • Child homicide deaths: education of physicians, social workers, law enforcement and other mandated reporters in recognition of signs of abuse and the creation of integrated multi-agency standard operating procedures

 

References:

  1. Armstrong E J. Chapter 8 Section 8.5: The Clinician Certifier of Death-Peri-procedural and Therapy-Associated Death Certification. In: Essentials of Death Reporting and Death Certification: Practical Applications for the Clinical Practitioner. 2017. Available at: https://www.amazon.com/Essentials-Death-Reporting-Certification-Applications/dp/0998533408 .
  2. Armstrong E J. Chapter 7: The Lethal Potential of Disease. In: Essentials of Death Reporting and Death Certification: Practical Applications for the Clinical Practitioner. 2017. Available at: https://www.amazon.com/Essentials-Death-Reporting-Certification-Applications/dp/0998533408 .
  3. MedWatch: The FDA Safety Information and Adverse Event Reporting Program. Available at: https://www.fda.gov/safety/medwatch/ .
  4. Fowler KA, Jack SPD, Lyons BH, et. al. Surveillance for Violent Deaths-National Violent Death Reporting System 18 States, 2014. MMWR Surveill Summ. 2018 ;67(SS-2):1-36. Available at: http://dx.doi.org/10.15585/mmwr.ss6702a1 .
  5. Centers for Disease Control and Prevention. Motor Vehicle Safety: Distracted Driving. Available at: https://www.cdc.gov/motorvehiclesafety/distracted_driving/index.html .
  6. Centers for Disease Control and Prevention. U.S. Drug Overdose Deaths Continue to Rise; Increase Fueled by Synthetic Opioids. Available at: www.cdc.gov.
  7. Centers for Disease Control and Prevention: Unintentional Drowning-Get the Facts. Available at: https://www.cdc.gov/homeandrecreationalsafety/water-safety/waterinjuries-factsheet.html .
  8. Centers for Disease Control and Prevention: Child Abuse and Neglect Prevention. Available at: https://www.cdc.gov/violenceprevention/childabuseandneglect/index.html .
  9. National Coalition Against Domestic Violence Fact Sheet. Available at: https://www.speakcdn.com/assets/2497/domestic_violence2.pdf .
  10. Deaths from Falls Among Persons Aged ≥65 Years –United States, 2007-2016. MMWR 2018:67:509-514. Available at: http://dx.doi.org/10.15585/mmwr.mm6718a1 .

 

Mind Your Manners. Avoid A Query.

“…but in this world nothing can be said to be certain, except death and taxes”-Benjamin Franklin, 1789.

It is also pretty certain, that a clinician practicing in a primary care specialty will on more than one occasion during his/her career encounter the death of a patient and be called upon to certify the death. Collectively, clinicians certify the majority (about 80 %) of deaths as compared to those certified by medical examiners and coroners (1,2). Those of you who follow the Practice Pearls site regularly know why getting it right matters and the consequences of getting it wrong.

Consider the cause of death statement below taken from an actual death certificate involving a death that  was certified in lieu of reporting to the local Medical Examiner. It was promptly flagged by an astute Vital Statistics professional. Can you identify the reasons why?

Part I.

 

A.                  Pneumonia-Aspiration poss.

Approximate interval: Onset to death

1 day

Due to (or as a consequence of):

B.                  Dysphagia

 

6 months

Due to (or as a consequence of):

C.                   Quadriplegia

 

3 years

Due to (or as a consequence of):

D.

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

Natural

 

References:

  1. Cambridge B and Cina SJ. The accuracy of death certificate completion in a suburban community. Am J Forensic Med Pathol. 2010;31(3):232-35.

2. Armstrong E J. Chapter 8: The Clinician Certifier of Death. In: Essentials of Death Reporting and Death Certification: Practical Applications for the Clinical Practitioner. 2017. Available at: https://www.amazon.com/Essentials-Death-Reporting-Certification-Applications/dp/0998533408 .

Dead Man Talking: Revelations of the Afterlife

The dead really do speak-at times in volumes. Their interpreter: The Forensic Pathologist. What is apparent to the eyes may not be what dwells within. The placid façade of the deceased can hide many internal truths.

  • the swimmer found submerged who didn’t drown but had a heart attack
  • the driver’s heart attack that caused the motor vehicle collision not drug or alcohol impairment or negligence
  • the patient treated for a migraine who following discharge from the hospital succumbed at home to a ruptured brain aneurysm
  • the young woman with a recent onset of shortness of breath with treatment for asthma and no further clinical workup despite the additional history of oral contraceptive use, is found at autopsy to have a pulmonary embolism
  • the elderly man with chronic heart disease whose loosened tooth found obstructing his airway at autopsy led to an abrupt asphyxial death
  • the tall and thin young man found at autopsy to have an aortic dissection and congenital aortic valve deformity; genetic screening for  Marfan Syndrome is recommended for the man’s parents and siblings
  • the frail elder found deceased with multiple bruises but by history was prescribed blood thinners for atrial-fibrillation, has senile purpura, and found at autopsy to have died from heart failure and not physical abuse
  • the accidental fall victim with atlanto-occiptial dislocation and spinal cord injury who had no pain or suffering
  • the gunshot wound victim with a perforating back wound was indeed running away from the suspect contrary to the suspect’s claim of self-defense

By way of medical training and practical experience, the forensic pathologist translates signs and symptoms of injury and disease into meaningful messages that impact the living (1,2). The messages and the mediums  include:

  • Cause-of-Death statements on the Death Certificate
  • Expert medical testimony in courts of law
  • Drug-related death trends compiled in statistical reports
  • Case reports, case series, and original research published in medical journals

References:

  1. Adelson, L. Forensic pathologist. “family physician” to the bereaved. 1977. JAMA. 237(15):1585-88. Available at: https://www.nhms.org/sites/default/files/Pdfs/Adelson_JAMA_Forensic_Pathologist_1977.pdf .
  2. Armstrong E J. Chapter 6: Forensic Pathology. In: Essentials of Death Reporting and Death Certification: Practical Applications for the Clinical Practitioner. 2017. Available at: https://www.amazon.com/Essentials-Death-Reporting-Certification-Applications/dp/0998533408 .

 

Mandated Reporting: “If you see something, say something and DO something…”

…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 .

References:

  1. 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 .
  2. 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 .
  3. 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 .
  4. “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/ .
  5. 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 .
  6. 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 .
  7. 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 .
  8. 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 .

Extra! Extra! Read All About It!

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.

 

References

  1. 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 .
  2. 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 .
  3. Heroin/Fentanyl/Cocaine-Related Deaths in Cuyahoga County 2017. Available at: http://medicalexaminer.cuyahogacounty.us/pdf_medicalexaminer/en-US/HeroinFentanylReports/100517-HeroinFentanylCocaine-Sept2017.pdf.
  4. 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 .
  5. Hill J. The urine drug screen. Know thy limitations. February 2016. Available at: http://www.tamingthesru.com/blog/intern-diagnostics/uds-know-thy-limitations .
  6. National Drug Early Warning System (NDEWS) Special Report. Fentanyl and Fentanyl Analogues. December 2015. Available at: http://pub.lucidpress.com/NDEWSFentanyl/ .

How comprehensive is clinical medical resident education really?

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.

 

References:

  1. 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
  2. https://www.cdc.gov/nchs/nvss/writing_cod_statements.htm
  3. http://www.massmed.org/Continuing-Education-and-Events/Online-CME/Courses/Cause-of-Death-Training-for-Medical-Certifiers/Cause-of-Death-Training-for–Medical-Certifiers/
  4. https://www.acponline.org/clinical-information/clinical-resources-products/end-of-life-care/papers-by-the-end-of-life-care-consensus-panel
  5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4077186/pdf/nihms584235.pdf