Jeffrey M. Jentzen

Criteria for the Interpretation of Cocaine Levels in Human Biological Samples and Their Relation to the Cause of Death

The determination that cocaine is directly responsible for the immediate cause of death should be considered only when there is a reasonably complete understanding of the circumstances or facts surrounding the death. Another, more obvious and immediate cause of death must be absent, or, at least cocaine must be shown to be a significant contributing factor in the chain of medical findings that lead directly to the immediate cause of death. Not all death investigation requires the sequential steps described in this paper, but these steps must be considered early on in the investigation whenever there is scene, investigational, medical or a historical basis to believe that cocaine is directly related to the cause of death. A relatively high profile death when cocaine is known to be involved, or a death involving unusual behavior on the part of the deceased with police involvement are examples where these considerations may well apply. Information needs to be obtained as soon as possible to have the highest chance of successfully documenting the toxicologic basis for the diagnosis. These facts would include, but would not necessarily be limited to, a scene investigation (whenever possible), a careful review of the investigative reports from all involved agencies, the initial core temperature of the body as well as that of the environment at the time of the collapse or death, the past medical history of the individual, and the results of a complete forensic autopsy and toxicologic studies. Knowledge of and an understanding of the current relevant forensic literature on this subject should be available to the reviewer prior to any interpretation of the significance of cocaine upon a specific death.

Retinal hemorrhages in children following fatal motor vehicle crashes: a case series

OBJECTIVE To demonstrate the severity of ocular findings in young children who died of injuries due to motor vehicle crashes. METHODS Case series of 10 children younger than 3 years who were fatally injured in motor vehicle crashes between January 1, 1994, and December 31, 2002. All children underwent autopsy that included eye examination. All available medical and autopsy records, pathology slides and photographs, and police and traffic department reports were reviewed for each case. RESULTS Eight patients had retinal hemorrhages, which extended into the periphery in 13 eyes and were bilateral in 7 patients. Three patients had elevated circular retinal folds. Six patients had hemorrhages below the internal limiting membrane, but no patients had deeper splitting of the retina. Nine patients had optic nerve sheath hemorrhages. CONCLUSION The association of extensive, sometimes severe, ocular hemorrhages with fatal accidental trauma, compared with previous reports of accidental trauma with no or few hemorrhages, indicates the severity of injury required to cause hemorrhages of this magnitude.

Guidelines for Postmortem Protocol for Ocular Investigation of Sudden Unexplained Infant Death and Suspected Physical Child Abuse

Postmortem examination is a cornerstone in identifying the cause of unexplained sudden death in children. Even in cases of suspected or known abuse, an autopsy may help characterize the nature of the abuse, which is particularly important in the forensic autopsy of children in the first 3 to 4 years of life when inflicted neurotrauma is most common. Forensic examinations are vital in cases that might otherwise be diagnosed as sudden infant death syndrome. The ocular autopsy in particular may demonstrate findings that were not appreciated on antemortem clinical examination. This protocol for postmortem examination of the eyes and orbits was developed to promote more consistent documentation of findings, improved clinical and forensic decision making, and more replicable and coherent research outcomes.

Death after discharge from the emergency department

STUDY OBJECTIVE To determine the rate and cause of death of patients who were evaluated in the emergency department and discharged and how the cause of death related to the ED visit. DESIGN Retrospective chart review of medical examiner cases from July 1, 1990, to June 30, 1991. SETTING Urban county served by 13 hospital EDs with 383,416 visits in 1991. Eighty-five percent of these patients were discharged. PARTICIPANTS Medical examiner cases of patients who had been evaluated and released from an ED within 8 days prior to death. RESULTS Forty-two of the 2,665 medical examiner cases met inclusion criteria. Death was classified as expected or unexpected based on the patients clinical status at the time of discharge, and directly related or not directly related to the ED visit, based on review of all records and the cause of death as listed on the death certificate. Six deaths (14%) were considered expected and directly related. Three deaths (7%) were considered expected and not directly related. Twenty-four deaths (57%) were considered unexpected and not directly related. Nine deaths (21%) were considered unexpected and directly related; the most common cause was ruptured aortic aneurysm, occurring in three of these nine cases. The death rate was 13 per 100,000 discharged patients. CONCLUSION Death after discharge from the ED is uncommon. The most common cause of unexpected, directly related death is ruptured aortic aneurysm.

From personalized medicine to personalized justice: the promises of translational pharmacogenomics in the justice system.

Enabled by Pharmacogenomics (PGx), molecular imaging, and other molecular biomarkers, personalized medicine (PM) promises to optimize therapy while minimizing side effects. It may also dramatically impact the justice system in ways we are only beginning to understand.

Selecting forensic pathology as a career: a survey of the past with an eye on the future.

Background: Each year there are about 30 to 40 physicians who train and become board-certified in the specialty area of forensic pathology, compared with hundreds or thousands in other disciplines. There are not enough board-certified forensic pathologists to cover national need. The National Association of Medical Examiners’ (NAME) Forensic Pathology Training Committee conducted a survey of its members to determine which factors influenced them to select forensic pathology as a career, and to offer suggestions about possible recruitment methods in the future. Methods: Two of the authors developed a 13-question survey form that included questions designed to determine the demographics of the responders, education level at which interest emerged, influential factors in the selection of forensic pathology, exposure to the subject matter of forensic pathology in medical school and residency, opinions about the best educational level for recruitment targeting, and faculty reactions to selection of forensic pathology as a career choice. Comments and suggestions were also solicited. The survey was sent by email to the 552 physician NAME members who have email addresses on file at the NAME Home Office. Results: One hundred sixty-one surveys were returned for a response rate of 29%. Most responders were full-time, board-certified forensic pathologists who had been practicing for an average of 18 years. The most influential factors in developing interest were exposure to forensic pathology in residency training and the influence of a professor or mentor. Medical school was the favored education level to target recruitment. Less than half had a forensic pathologist as an autopsy instructor in anatomic pathology residency. The number of responders who were encouraged by faculty to pursue forensic pathology was about the same as the number who were either discouraged or who perceived no particular positive or negative reinforcement. The typical scenario for forensic pathology exposure during anatomic pathology residency was a 4-week rotation at an off-site location from the medical school or hospital, with a mentor that had an adjunct, assistant, associate, or clinical faculty appointment. Conclusions: If the past predicts the future, it will be important to ensure that pathology residents have a planned and positive exposure to forensic pathology and that forensic pathologist mentors are available to training programs. There are a variety of other methods that might be used for recruitment which include more emphasis on medical students, a more academic approach, and affiliation, emphasizing the scientific nature of the work, integrating forensic pathology more into the ongoing medical school curriculum, improving the anatomic pathology residency autopsy experience, and avoiding possible turnoffs that can be caused by presentation of sensational or unpleasant cases that are not representative of routine daily work. Improved remuneration and building esteem by peers were also cited as critical factors, as was recruitment of more physicians into pathology in general. The Committee intends to develop a plan for recruitment and retention in the field of forensic pathology. Based on the survey data, this will require a conjoined effort with the American Association of Medical Colleges, the Accreditation Council on Graduate Medical Education, the Association of Pathology Chairman, and other entities to enable a planned and multifaceted approach to recruitment and retention in the field.

Tandem Bullet Versus Multiple Gunshot Wounds

The differentiation of tandem bullets fired simultaneously versus multiple bullets fired separately entering through a single entrance wound may present difficulty in wound interpretation for the forensic pathologist. The authors present a case report of three separate projectiles entering through a single perforation. The differentiation of projectiles fired in tandem and multiple single projectiles is discussed.

Medicolegal death investigator preemployment test development

The medicolegal death investigator (MDI) represents an essential component in the multidisciplinary investigation of sudden and unexpected deaths. Presently there exists no specific program for the job training evaluation procedure for new (MDI) employees. We discuss the development of a medicolegal death investigator preemployment training tool, which consists of a training and evaluation program containing a list of tasks and task steps. After the investigator demonstrates the ability to perform individual tasks independently, the trainee will be objectively evaluated by the completion of a written test specifically designed to cover the task items. The preemployment test has been developed by those professionals best able to determine the job requirements, the death investigators. The specific outcomes of the process also include further definition of the profession, preemployment testing, policy and procedure development, posttraining evaluation, identification of training needs, curriculum design and further professional development, and identification of the profession of death investigator.