Calle Winskog

Recent Trends in Suicides Utilizing Helium

Abstract:  Retrospective review of cases of suicide involving helium inhalation was undertaken at Forensic Science South Australia over a 25‐year period from 1985 to 2009. No cases of helium‐related suicides were identified in the first 15 years of the study, with one case between 2000 and 2004 and eight cases between 2005 and 2009. Australian data were also reviewed from 2001 to 2009 that showed 30 cases between January 2001 and June 2005, compared to 79 cases between July 2005 and December 2009, an increase of 163%. A review of Swedish data between 2001 and 2009 showed no cases between January 2001 and June 2005, compared to seven cases between July 2005 and December 2009. Thus, all three areas showed recent and striking increases in cases of suicide involving helium inhalation. Given the availability of helium and the recent promotion of this method of suicide, it is quite possible that this may represent a newly emerging trend in suicide deaths.

Potential problems arising during international disaster victim identification (DVI) exercises

Disaster victim identification (DVI) refers to the formal andorganisedprocessofidentifyingmultiplebodiesafter amassfatality. The number of dead required before DVI processesare initiated varies among jurisdictions, for example it mayoccur with only four bodies after a vehicle crash, or withmany thousands after a tsunami. International DVI proce-dures are coordinated through Interpol with local authoritiesgenerally having control over the site(s) of the disaster, butsometimes with assistance from outside organizations.Guidelines and internationally accepted forms are providedby Interpol for collating both antemortem and post-mortemdata. DVI exercises may involve recent natural disasterssuch as earthquakes, terrorist actions such as suicidebombings, human trafficking accidents, or events that havehappened some time ago, as in exhumations of mass gravesfrom previous armed conflict [1].A variety of problems can occur when large operationsare commenced on foreign soil. Given the high level ofinterest in such exercises amongst forensic professionalsthere is often quite a strong push for participation when ahigh profile disaster occurs. This results in rapid mobiliza-tion of teams and individuals, sometimes without adequate,or any, consultation with localauthorities. This international‘‘DVI industry’’may result indeployment of individualsandteams that may include some who are not engaged in currentprofessional practice, and also conversely in significantdeskillingofthoseleftbehind–anundesirableeffectonbothcounts. It is important to ensure that all forensic profes-sionals are trained in this area as it is preferable, where thescaleallows,thatlocaldisastersarehandledbylocally-basedprofessionals, as they are the ones who have the bestunderstanding of many of the local issues.Operating in an external jurisdiction also brings with itcomplex legal and cultural issues. The impression some-times given to local authorities is that they are merelybeing tolerated by the true ‘experts’ in the field, howeverthe reality is often far from this. Cultural sensitivities areextremely important and every effort should be made for anexperienced team leader and team members to be ade-quately briefed on local religious beliefs, cultural attitudesand practices, and political systems [2]. This may onlyrequire the application of common sense, such as con-sulting regularly with local authorities before any changesin work practices occur, or simply not placing a visitor’sflag over a national flag at a work site.Amultidisciplinary approach is essential tothe successofthese operations with input from representatives of all majorprofessional groups. It is important to maintain this multi-disciplinary interaction from the initial planning stages rightthroughtosigningoffcasesatReconciliationPanelmeetingsbetween visiting experts and local authorities. For example,failure to consult with pathologists in the early stages ofplanning may result in inadequate sampling being under-taken, which then necessitates reprocessing of cases for asecond or even a third time, all of which is exceedingly timeconsuming and expensive. One of the most important phi-losophies is to ‘hasten slowly’, as the consequences of errorsin identification due to rushed work could outlast the oper-ation by many years, if not decades.Once in the field it is important that the health of theteam is cared for, and this includes both psychological and

Wischnewski spots and hypothermia: sensitive, specific, or serendipitous?

Hypothermia develops when regulatory mechanisms suchas vasoconstriction and heat production fail to compensatefor heat loss to the environment and the core temperature ofthe body falls below 35 C. Severe cases may be fatal withdeath resulting from myocardial ischemia and/or hypoxia,exacerbated by electrolyte abnormalities and elevated cat-echolamine levels. The mortality rate exceeds 70 % whenthe core temperature drops to 30 C, and reaches 90 % at26 C[1, 2].Causes of hypothermia include accidental exposure tolow environmental temperatures, either outdoors or inside,the latter occurring from inadequately heated houses. It hasbeen shown that hypothermic deaths may occur in areaswhere the external temperatures are not markedly lowered.Exacerbating factors include damp conditions, inadequateor wet clothing and air movement [3]. Individual suscep-tibility is increased by the ingestion of alcohol and certainprescribed or illicit drugs. In addition, low muscle mass,immobility, trauma, open injuries, and certain cardiovas-cular, neurological, endocrine and psychiatric disordersincrease the risk. An age-related susceptibility is alsofound, with children and the elderly being the most vul-nerable [1].The pathological diagnosis of hypothermia may be dif-ficult, as body temperatures at the time of death are usuallynot available at autopsy and so the circumstances of deathare of considerable importance in formulating the diagno-sis. In addition, morphological features are subtle and notwell understood. Characteristic findings that have beendescribed at autopsy include pinkish discoloration of theskin over the extensor surfaces of large joints, such as theelbows, knees and hips, acute pancreatic inflammation withfat necrosis, fatty change in cells of the heart, liver andkidneys, skeletal muscle hemorrhage, vacuolization ofrenal tubular cells, and superficial gastric lesions that havebeen called Wischnewski spots [1, 2, 4–7]. It is the latterfinding that we would like to examine in greater detail.In 1895 a Russian district medical officer, SM Wisch-newski, reported multiple superficial hemorrhagic lesionsof the gastric mucosa in 91 % of the cases of fatal hypo-thermia that he had examined. A contemporary translationof his original paper states: ‘‘On the mucous membrane ofthe stomach in humans who have died exclusively from theeffects of low temperatures, 5–100 hemorrhages areinvariably present. Their size ranges from 0.5 to 1.0 cm.They have a round to oval form. Sometimes they arepunctiform and lie about 1–2 inches apart. These hemor-rhages are raised slightly above the surface of the mucousmembrane, can be very easily scrapped (sic) away andleave behind nothing conspicuous on the gastric mucosa.’’[8] (Fig. 1). They have also been documented in ectopi-cally situated gastric mucosa [9].Although Wischnewski described raised hemorrhagicareas that could be easily removed from the mucosa, theywere subsequently considered to be ulcers or erosions[3, 10, 11]. In an immunohistochemical study by Tsokoset al. however it was proposed that the lesions resultedfrom the action of gastric acid on hemoglobin in areas ofinterstitial mucosal hemorrhage, and not from ulceration[7]. A photomicrograph in a chapter by Madea et al. [2](Fig. 1.4B) clearly demonstrates protrusion of one of thespots above the surface of the surrounding mucosa, and notulceration. Conversely, Hirvonen and Elfving reportedthat the erosions extended ‘‘halfway through the mucosa’’and that hemorrhage was ‘‘not always present’’ [12].

Why are Wischnewski spots not always present in lethal hypothermia? The results of testing a stress-reduced animal model

Hypothermic fatalities in humans are characterized by a range of often subtle pathological findings that typically include superficial erosive gastritis (Wischnewski spots). Experimental studies have been successfully performed using animal models to replicate this finding, however study animals have inevitably been subjected to a variety of additional stressors including food deprivation, restraint and partial immersion in water while conscious. As it is recognised that stress on its own may cause superficial erosive gastritis, a model has been developed to enable the study of the effects of hypothermia in isolation. 42 Sprague-Dawley rats were allowed free social contact and were fed and watered ad libitum prior to being anaesthetized with isoflurane. Once unconscious, rats were placed on drape cloth covering metal mesh platforms in a styrofoam box packed with ice. The apparatus enabled both maintenance of a specific low temperature (26 °C) in 14 animals, and continued reduction of core temperatures in the remaining 28 (who all died of hypothermia under anaesthesia). Examination of the gastric mucosa in both groups macroscopically and microscopically failed to demonstrate typical Wischnewski spots in any of the 42 animals. Thus, in this model, death from hypothermia occurred without the development of these lesions. These results suggest that stress may be a significant effect modifier in the development of Wischnewski spots in lethal hypothermia.

Underwater disaster victim identification: the process and the problems.

An underwater disaster may involve a crime scene investigation which should be handled as if it were located above water and include a detailed description and documentation of items, belongings and findings. The environment, however, creates special circumstances, each with specific problems that are not encountered during land investigations. Risks associated with underwater recovery cannot be overestimated and underwater disaster recovery diving should not be performed without special training and careful pre-dive planning. Handling of cadavers in an underwater recovery operation also requires special training and a systematic approach to victim recovery. Environmental circumstances, local judicial requirements, religious and cultural issues and the scope of the disaster are only some of the factors that have to be considered before commencing any aquatic disaster victim recovery operation.

Histology in forensic practice: required or redundant?

One of the mainstays of traditional autopsy practice has been the performance of extensive histological examination of tissues. Part of this practice arose out of the academic approach taken by major English, German and other European centers in the nineteenth century, with the requirement for detailed microscopic analysis of tissues being carried over into subsequent centuries. In contemporary forensic practice, however, the emphasis is somewhat different and this has led to ongoing discussion and debate as to the usefulness and cost-effectiveness of routinely performing a standard set of histology in all cases. The ‘‘complete’’ autopsy was also motivated by a desire to collect material for current and future scientific research, however new legislation on the retention of human tissues in a number of jurisdictions has substantially reduced the possibilities for pathologists to do this. In this Commentary the case for and against routine histology is discussed, with the need for maintaining high volume histology in all cases countered by a call for a more rationalized evidence-based approach. Forensic pathologists who were initially trained in anatomic pathology are often the most enthusiastic samplers of tissues for microscopy. This behaviour is generated by a combination of factors that includes an appreciation of histologic morphology and a genuine belief that microscopy may reveal occult conditions that were not apparent on macroscopic examination [1, 2]. During their training such pathologists were often exposed to the aphorism: ‘‘when in doubt sample,’’ and so have been used to taking many samples from multiple organs. Certainly, very few would argue against using histology to confirm a macroscopic impression of disease, or to clarify an underlying process e.g. inflammation or tumor, or to quantify the amount of disease present. In a decedent with a highly complex medical history histology may be the only way to determine what diseases were active, and which may have significantly contributed to the lethal episode. But does the documentation of disease always need to be histological? For example, techniques such as digital photography can now accurately and rapidly record conditions such as atherosclerotic coronary artery disease. Does histology in this instance assist in interpretation, in the absence of possible thrombus or plaque hemorrhage? An issue that sometimes arises in forensic practice concerns the limited amount of clinical history that may be made available to the pathologist at the time of autopsy. Every forensic pathologist has had cases where significant medical information has been provided days or weeks after the autopsy has been finished with the decedent already buried or cremated. The advantage of having taken tissues for histology is that further investigation is still possible. An example might be a history of iron overload raising the possibility of hereditary hemochromatosis, which may have a direct and significant impact on surviving family members. Excessive iron stores in tissues may not have been obvious at the time of autopsy dissection illustrating a potential problem in deciding whether or not to sample tissues for histology based on a ‘‘normal’’ appearance. One way to avoid this problem would be to take tissue samples, but not to process them into slides unless there was a diagnostic reason to do so. This of course does not uncover occult cases of hemochromatosis that would only have been identified on routine histology. A similar problem R. W. Byard (&) C. Winskog Discipline of Anatomy and Pathology, The University of Adelaide, Level 3 Medical School North Building, Frome Rd, Adelaide, SA 5005, Australia e-mail: roger.byard@sa.gov.au

Autoerotic death: incidence and age of victims--a population-based study.

Abstract:  Review of the Australian National Coronial Information System and the Swedish National Forensic Database was undertaken over a 7‐year period from 2001 to 2007 for all cases where death had been attributed to autoerotic death or sexual asphyxia. In Australia, there were 44 cases (M:F = 42:2) with the majority of victims aged >30 years (77%)—a yearly national rate of approximately 0.3/million. In Sweden, there were nine cases (M:F = 9:0) with the majority of cases aged <30 years (55%)—a yearly national rate of approximately 0.14/million. The usual male predominance was present in both populations, although the Australian victims were older than is usually reported. Lethal sexual asphyxia is uncommon in both the Australian and Swedish populations, with a lower rate than has been cited for North America. Whether this is because of different kinds of paraphilic activities in different populations or of differences in methods of central data collection is uncertain.

The educational value of disaster victim identification (DVI) missions—transfer of knowledge

Transfer of knowledge is the cornerstone of any educational organisation, with senior staff expected to participate in the training of less experienced colleagues and students. Teaching in the field is, however, slightly different, and a less theoretical approach is usually recommended. In terms of Disaster Victim Identification (DVI) activities, practical work under supervision of a field team stimulates tactile memory. A more practical approach is also useful when multiple organizations from a variety of countries are involved, as language barriers make it easier to manually show someone how to solve a problem, instead of attempting to explain complex concepts verbally. “See one, do one, teach one” is an approach that can be used to ensure that teaching is undertaken with the teacher grasping the essentials of a situation before passing on the information to someone else. The key principles of adult learning that need to be applied to DVI situations include the following: participants need to know why they are learning and to be motivated to learn by the need to solve problems; previous experience must be respected and built upon and learning approaches should match participants’ background and diversity; and finally participants need to be actively involved in the learning process. Active learning involves the active acquisition of knowledge and/or skills during the performance of a task and characterizes DVI activities. Learning about DVI structure, activities and responsibilities incorporates both the learning of facts (“declarative knowledge”) and practical skills (“procedural knowledge”). A fundamental requirement of all DVI exercises should be succession planning with involvement of less experienced colleagues at every opportunity so that essential teaching and learning opportunities are maximized. DVI missions provide excellent teaching opportunities and international agencies have a responsibility to teach less experienced colleagues and local staff during deployment.

Cardiovascular Conditions and the Evaluation of the Heart in Pregnancy-Associated Autopsies

Abstract:  Pregnancy‐associated death is defined as the death of a woman from any cause during pregnancy or in the year after delivery. This review concentrates on cardiac conditions that may result in pregnancy‐associated death including, but not limited to, acute myocardial infarction, endocarditis, peripartum cardiomyopathy, and prolonged QT syndrome. Lethal vascular conditions may also occur involving arterial dissection and thromboembolism, on occasion exacerbated by hypercoagulability, and altered hormonal and physiologic states. The autopsy evaluation of these patients includes a careful assessment of the medical history particularly for prior pregnancy‐related conditions, fetal loss, and episodes of unexplained collapse. A family history of sudden death at an early age may be significant. At autopsy, evaluation for underlying syndromes such as Marfan, or evidence of intravenous narcotism should be undertaken. Autopsy examination involves careful dissection of the heart and vessels with consideration of conduction tract studies and possible genetic evaluation for prolonged QT syndrome.

The progression from disaster victim identification (DVI) to disaster victim management (DVM): a necessary evolution

This issue of Forensic Science, Medicine and Pathology presents a wide range of papers that deal with all aspects of disaster victim identification (DVI). The focus of many of the submissions has been on the expanding role of individual disciplines, the refining and integration of services, the formulation and implementation of international protocols, and the overview of processes to ensure that they are fulfilling their role appropriately. In short, this issue demonstrates the evolution of simple victim identification into the complex integrated approach that is now seen in so many of these events. It encompasses all aspects of such exercises that should now be included under the broader umbrella of disaster victim management (DVM), rather than merely identification. This issue deliberately contains many papers that do not represent original research, but instead summarize approaches to situations and methodology. This resulted from a decision by the editors to make this issue useful as a handbook for developing local DVI/M programs, in addition to being able to be taken to disaster areas as a practice manual. Previous papers in the journal have dealt with practical aspects of constructing facilities in disaster areas, as well as on the problems that may arise from difficult work being conducted in under-resourced and sometime isolated locations by a large number of individuals with different nationalities, languages and experience [1, 2]. In this issue the scope of topics has expanded considerably. One of the fundamental requirements in disaster situations with multiple fatalities is the correct identification of victims [3]. Original papers in this issue that provide data to improve the evaluation of victims include an approach to age estimation in children based on an assessment of both dental and cervical vertebral maturation [4] and an examination of teeth and cranial size in assisting with the determination of gender [5]. A Commentary by Bassed gives an overview of methods of age estimation [6] and a Letter to the Editor by Wikwanitkit [7] draws attention to possible confounders of age estimation in children. The potential roles of experts in particular fields have been reviewed for anthropologists [8], biologists [9], dentists [10] and pathologists [11]. Training and education in DVI/M is something that is often discussed, but which is usually undertaken at a local level without the benefit of established guidelines or an agreed upon philosophical approach. Winskog et al. [12] discuss an educational approach to DVI/M with Rutty et al. [13] providing suggestions for organizers of DVI/M training events on how to increase the training value for participants. A template for setting up an emergency mortuary facility is provided by Eitzen and Zimmerman [14]. Several papers deal with specific situations. For example, Schou and Knudsen [15] discuss the work of Danish teams in Thailand following the 2004 tsunami, and one of the guest editors, Calle Winskog, reports on issues that arose with the identification of the remains of a group of African men, victims of human trafficking, who were found in a boat drifting in the Caribbean, and also on the approach to DVI/M situations that occur in underwater environments [16, 17]. Although the paper by Hoyer et al. [18] only deals with two cases, it clearly demonstrates how C. Winskog R. W. Byard (&) Discipline of Anatomy and Pathology, Level 3 Medical School North Building, The University of Adelaide, Frome Road, Adelaide, SA 5005, Australia e-mail: roger.byard@sa.gov.au