Principles of Forensic Pathology: From Investigation to Certification

Front Cover
PRINCIPLES OF FORENSIC PATHOLOGY
PRINCIPLES OF FORENSIC PATHOLOGY
Copyright
Dedication
Contents
List of contributors
In memoriam
References
Biography
SUSAN F. ELY
Biography
JAMES R. GILL
Foreword
Preface
Acknowledgments
ABOUT THE ARTIST (COVER ART AND ALL MEDICAL ILLUSTRATIONS)
1 - Forensic pathology: overview
Introduction: who we are and our unique role as physicians
Historical perspective
Coroner versus medical examiner systems in the United States and abroad
What constitutes “medical examiner/coroner jurisdiction”?
The forensic autopsy (see also Chapter 5)
Death certification (see also Chapter 3)
Planning for a career in forensic pathology: advice to future trainees
References
2 - Thinking forensically: planning, anticipating, observing, documenting, inquiring, synthesizing, opining, and co ...
The importance of context
The role of inference: releasing the grip on exclusively anatomic findings
Objectivity, neutrality, and observational acumen: being autoptic
Anticipating, planning, observing, documenting, inquiring, synthesizing, opining, and communicating, in that order
Preautopsy analysis and planning
Anticipating questions and future issues
Postautopsy analysis and planning
Observing and documenting
Documentation
The value of pertinent negatives
Considering disease and injury lethality
Injury pattern recognition
Consider the mechanism of death before leaving the autopsy room
Inquiring
Interpreting and synthesizing
Opining
Possibilities
Probabilities
Reasonable degree of medical/scientific certainty∗∗
Certainty beyond a possible doubt (100% certainty)
Making “pending” death certification decisions
Communicating
References
3 - The pathophysiology of death and death certification
The pathophysiology of death
Death certification
Cause of death
“Pending” death certificates
Common death certificate mistakes
Manners of death
Natural deaths
Therapeutic complications
Accidents
Suicides
Homicides
Undetermined cause and/or manner
War injury
Other death certificate fields and miscellaneous issues
Injury information
The importance of “how injury occurred”: Do's and Don'ts
Time of death/found/pronounced and miscellaneous information
Assigning gender on death certificates
Injury at work
YES
NO
Death certificates in disasters/mass fatality incidents (see also Chapter 4)128
Key death certification tips
References
4 - The scene investigation, postmortem changes, and time of death
The written narrative
General tips
Anaphylaxis and food
Asthma/emphysema
Bathtub deaths (see also Chapters 6 and 11)
Cancer
Carbon monoxide (nonfire) (see also Chapter 14)
Choking on food (see also Chapter 11)
Communicable disease (e.g., tuberculosis, meningitis, CJD, etc.; see chapter 17)
Tuberculosis and meningitis
AIDS/HIV
Creutzfeldt–Jakob disease
Novel coronavirus (COVID-19)
Delayed hospital deaths following recent or remote injury (see also Chapter 15)
Descent (fall versus jump) from height
Diabetes mellitus
Drowning (see also Chapter 13)
Drugs and ethanol/substance misuse deaths (see also Chapter 14)
Communication with families (see also Chapter 16)
Family preferences for and objections to autopsy
Final exit suicides (see also Chapter 11)
Fire (see also Chapter 12)
Gastric bypass surgery (see also Chapter 8)
Gunshot wounds (also see Chapter 9)
Head injury (also see Chapter 10)
Deaths following heart surgery
Hip fractures
Hospital bloods (see also Chapter 14)
Hyperthermia/hypothermia (see also Chapter 13)
Infants/newborns (see also Chapter 6)
Injuries in general
Kidney disease
Liver disease
Medications at scene
Motor vehicle collisions (see also Chapter 10)
Multiple medical diseases/potential causes of death
“No scene”/public view/direct to ME/C deaths
Obesity
Organ donation
Occupational safety and health administration–OSHA (see also Chapter 3)
Pregnancy (see also Chapter 3)
Seizures (see also Chapter 7)
Sharp injury (see also Chapter 10)
Stillbirths (versus live births) (see also Chapter 6)
Suicides
Sudden death
Surgeries and therapeutic complications121,122 (see also Chapter 8)
Time of death/found/pronounced
Postmortem changes and establishing the basis for postmortem interval estimates
Environmental variables
Bodily variables
Time of death versus time of pronouncement: reports and testimony
The trauma scene
Crime scenes and deaths in public view
Crime scenes
Deaths in public view
Field challenges in the recognition and identification of human skeletal remains
Attempts at postmortem concealment of bodies in homicides (dismemberment, incineration, and burial)
Mass fatality incidents (MFI)
Avoiding the top 10 investigative oversights
References
5 - The forensic autopsy
The big picture
The forensic autopsy: general tips
Photography
Radiography
Radiologic tasks and tips
Suggestions:
Evidence
Clothing
The sexual assault kit
Suspected weapons
Ballistics evidence
The standard external autopsy examination
The standard internal autopsy examination
Cardiovascular pathology
Neuropathology
Forensic anthropology
Toxicological sampling
Histology
Microbiology
Approach to the trauma autopsy
Special techniques and examinations
Eye enucleation
Intracardiac air embolism
The layered anterior neck examination
The posterior neck examination83–85
Concerns for sexual assault
Postmortem sperm harvesting
Pulmonary thromboembolus and posterior lower extremity dissection
Dissections of surgical and injection sites
Pedestrian fatalities: special procedures
Dissection of the facial soft tissues and skeleton
Full body flay
Autopsy of the pregnant or recently pregnant woman
The negative autopsy: the importance of what we exclude
Organ and tissue donation
Dissections and the funeral home
Religious objections to autopsy
The forensic team: investigators, technicians, clerical staff
Quality assurance
Safety in the autopsy environment
Sharp injury risk
Radiation risk
Cardioverter-defibrillator risk
References
6 - Approach to forensic perinatal and pediatric pathology
Initial investigation
Primary scene
Reenactment
Medical history
Radiology
Photography
The pediatric autopsy
External examination
Postmortem changes and artifacts
Evidence of therapeutic intervention
Clothing
Injuries
Internal examination
General
Body cavities
Head and spinal cord
Neck
Cardiovascular system
Respiratory system
Digestive system
Genitourinary system
Hematolymphoid system
Endocrine system
Musculoskeletal system
Histology
Neuropathology
Toxicology
Metabolic studies
Microbiologic studies
Molecular genetics
Forensic odontology
Forensic biology
Forensic anthropology
Pediatric trauma
Blunt impact injuries
Fatal child abuse syndrome (aka, battered child syndrome) and abusive head trauma
Fatal child abuse syndrome
Abusive head injury
Patterns of inflicted injury: infants versus toddlers/preschoolers
Asphyxia
Bathtub drownings
Thermal injuries
Neglect
Consultations
Child fatality review boards
Mandatory reporting
Home births: stillbirth versus live birth
Approach to the live born versus stillborn infant/fetus and possible neonaticide
Was the baby stillborn or live born?
Autopsy: determination of gestational age, live born versus stillborn, and cause of demise or death
Investigative issues and checklist
Potential etiologically specific causes of neonatal death or fetal demise
What is SUID, SIDS, SUDC, and SUDP?
Death certification
History of SIDS and sudden unexplained death in infancy
Conclusion
References
7 - Approach to natural deaths (adult)
The sudden and unexpected death
Sudden
Unexpected
Cardiac
Coronary arteries
Myocardium
Cardiac valves
The conduction system
Specific forensic issues in sudden cardiac death
Sudden death in young athletes103–109
Sudden cardiovascular death in hostile environments
Pulmonary thromboembolism
Seizure-related deaths and epilepsy
Seizure investigation
Posttraumatic epilepsy
Medications
Autopsy and postmortem work-up
Death certification
Anaphylaxis
Alcohol use disorder (formerly known as chronic alcoholism) and chronic substance use disorder
Alcohol use disorder
Chronic substance use
Pancreatitis
Gastrointestinal hemorrhage (GIH)
Bronchial asthma
Dementia and old age
Diabetes mellitus
Obesity as a cause of death
Bronchopneumonia
Sudden death and chronic renal disease
Sudden death from endocrine disorders
Sudden death and psychiatric disease
Sickle cell disease and trait
Human immunodeficiency virus
References
8 - Approach to medical intervention‐related deaths
Therapeutic complications
Categories and examples of therapeutic complications
Operative
Nonoperative
Procedural
Deaths related to cosmetic, weight loss, and dental procedures
Liposuction and fat transfer
Bariatric surgery
The dental office
Accidents and homicides in medical settings
Medical accidents
Medical homicides
References
9 - Approach to firearms deaths
Deaths due to trauma
Firearm injury
Graze and tangential gunshot wounds
Retractor artifact
Bullet “bookkeeping”
Range of fire
Penetrating gunshot wounds
Kinetic energy
Yaw
Bullet construction and configuration
Tissue factors (density, elasticity, and strength)
Intermediary objects/targets
Mechanisms of death in firearms fatalities
Manners of death in firearms fatalities: homicides, suicides, and accidents
Gunshot residue testing (GSR)
Rifles (rifled long guns)
Shotguns
Ballistics
Conclusion
References
10 - Approach to blunt, sharp, and transportation deaths
Blunt injury
Craniocervical trauma
Skull fractures
Epidural, subdural, subarachnoid, and intracerebral hemorrhages
Cerebral cortical contusions
Traumatic axonal injury
Secondary processes
Neck injury
Approach to unwitnessed fatal blunt head and torso trauma
Sharp injury
Chop injury
Sharp injury tips
Transportation injury
References
11 - Approach to asphyxial deaths
Asphyxia
Asphyxia: accidental and suicidal
Approach to potential choking deaths
Approach to lack of environmental oxygen
Approach to final exit (and similar) deaths
Approach to hangings
Characteristics of the ligature
Degree of suspension
Duration of suspension before body discovery
Placement of the ligature in the neck's vertical dimension
Location of the point of suspension
Approach to potential positional asphyxia deaths
Approach to asphyxia: homicides
Facial/Conjunctival petechiae and asphyxia
Loss of consciousness
Time to death
Carotid sinus and vagal inhibition
Manner of death
References
12 - Approach to burns, blast, and radiation injury
Thermal and inhalational injury
Fire
Scald and heat burns
Chemical/irritant burns
Blast/radiation injury
Blast injury
Radiation injury
Animal attacks, domestic and in the wild
References
13 - Approach to environmental deaths
Drowning
The approach to bodies in public waterways (pools/oceans/rivers/lakes)
Certification of waterway deaths
Scuba (air embolism)
Near-drownings
Electricity
Electrical burns
Electrocutions
The science of electricity
How does electricity kill?
Typical electrocution scenario and investigation
Lightning
Electromechanical control devices
Environmental exposure: hyperthermia
Environmental exposure: hypothermia
References
14 - Approach to toxicological deaths
History and scene investigation
Autopsy examination
Toxicology testing
Autopsy samples
Death certification
Opioids
Stimulants
Examples of drug intoxications
Opioids, benzodiazepines, and other depressants
The combination of opioids and stimulants
Novel (new) psychoactive substances
Opioids and natural and synthetic cannabinoids
Methadone
Three scenarios:
The effect of drug metabolism on toxicology results
Postmortem drug redistribution and breakdown
Natural disease in the presence of intoxicants
Toxicology testing and trauma deaths
Toxicology testing following hospitalization
Interpreting toxicology test results in the decomposed body
Drug packers (“Mules”)
Suicide versus accident
The apparent drug intoxication death with negative toxicology and no anatomic cause
Legal implications of mixed drug intoxications and other special toxicologic considerations
Miscellaneous toxicological issues
Nitrites and poppers
Cyanide
Arsenic
Ethylene glycol
Anticholinesterases
Acetaminophen
Sodium azide
Toxicological considerations in pediatric deaths
References
15 - Special topics: in-custody deaths, physical altercations, neglect (adult), approach to unexpected hemorrhage, ...
Deaths in detention centers/correctional facilities/police custody
Deaths in the setting of police restraint
Hyperactive delirium (so-called “excited delirium”)
Suicidal behavior in law enforcement encounters
The investigation
Police investigations and the medical examiner/coroner
Physical struggles: contact, altercations, and the death certificate
Abuse and/or neglect in the debilitated adult or teen
The establishment of dependence
Autopsy/physical evidence
Police/district attorney/forensic investigator evidence
Approach to hemorrhage of unclear origin (unexpected hemorrhage found at autopsy)
Head
Neck
Thorax
Peritoneal cavity
Gastrointestinal
Retroperitoneal and rectus sheath (soft tissue)
Delayed deaths due to remote injury: issues and concepts
Approach to dismembered remains and other forms of postmortem concealment
The forensic anthropologist
Dismemberment
Postmortem incineration
Postmortem burial
References
16 - Communication
Overview
Verbal: one-on-one communication
On speaking with families and to juries
Testifying in legal forums
Inquiries from attorneys
Testimony at depositions, grand juries, or trials
Depositions
Grand jury
Trial
Steps in the preparation for testimony
The courtroom
Standard qualification questions (with some examples of responses):
Typical direct examination questions:
Cross-examination questions:
Potentially challenging or otherwise tricky questions
Time of death estimates and postmortem changes: caveats and approach
Objections raised while on the stand
Testimony tips
Being called to testify in a former jurisdiction
Miscellaneous
Top 10 testimony tips
High-profile deaths, media inquiries, and press offices
Silence or nonresponsiveness
Handling individual inquiries from the media
Press releases
Press conferences
Interviews
Relationship with the media
Release of information
Consideration of families and the media
Tone
Mistakes
Public speaking: case presentations, lectures, and teaching
Case presentations
Formal lectures
Teaching
Written communication
Tips on crafting a forensic autopsy report
References
17 - The forensic pathologist's public health role
Introduction
Background
Passive surveillance
Vehicular fatalities
Occupational fatalities
Violent deaths
Active surveillance
Adverse medication/medical device events
Adverse vaccination events
Unsafe consumer product events
Death review teams
Identification of missing and unidentified persons
Detection and characterization of infectious disease
Conclusion
References
18 - Developments in postmortem imaging
Introduction
CT basics
Hounsfield units
Artifacts
Approach to PMCT interpretation
Head and neck
Chest
Abdomen and pelvis
Bones
Support devices
CT reporting
Example CT reporting template
Radiologic identification
Postmortem CT angiography
Image-guided procedures
Postmortem and decomposition changes on imaging
Mummification, skeletonization, predation, and charred remains
Mummification and skeletonization
Predation
Charred remains
Natural disease
Brain
Heart
Pulmonary
Liver
SARS-CoV-2 relating findings
Blunt force trauma
Blunt head trauma
Blunt neck trauma
Blunt chest trauma
Blunt abdominal trauma
Blunt extremity and pelvic trauma
Penetrating injury
Drug intoxication
Pediatric imaging
Appendicular fractures
Foreign bodies
Pro tips/pearls
Forensic pathology postmortem imaging training curriculum: the New Mexico experience
Future directions
References
19 - Recent and ongoing technological advancements in forensic pathology practice
The role of molecular genetics in sudden and unexpected deaths
Cardiac-focused
Aortopathies
Thrombophilias
Epilepsy-focused
Hemoglobinopathies
Rapid DNA
Digital fingerprinting
3D printing and anthropology
Facial reconstruction and recognition
References
I -
Appendices
A - Formats of autopsy report final diagnoses
General formats for final diagnoses lists
Gunshot wounds
Gunshot wounds with subsequent therapy
Blunt trauma
Reference
B - Format of the autopsy report
Formats for the “Injury” section
Gunshot wounds
Penetrating/perforating gunshot wound of2 …
Multiple gunshot wounds
Shotgun wounds
Blunt force trauma
Head and neck
Trunk/Torso
Extremities
Sharp force trauma
Stab wounds
Wound appearance
Incised wounds
. Asphyxia
. Thermal
C - Autopsy report templates
Autopsy templates by type
General/generic dictation template
External examination
Postmortem changes
Tattoos
Therapeutic/diagnostic procedures
Clothing
Injuries, external and internal
Internal examination
Microscopic tissue examination
Toxicology
Neuropathology/cardiac pathology
Microbiology
Molecular genetics
Forensic biology
Forensic imaging
Evidence: (examples)
Pediatric dictation
Generic pediatric autopsy dictation template
External examination
Placenta and umbilical cord
Postmortem changes
Therapeutic interventions
Injuries, external and internal
Internal examination
Microscopic tissue examination
Toxicology
Neuropathology/cardiac pathology
Microbiology
Molecular genetics
Metabolic studies
Forensic biology
Forensic imaging
Evidence
Gunshot/shotgun wound templates
Injuries, external and internal
Entrance wound
Notes
Track with associated injury/sequelae
Exit wound (or site of lodgment)
Course and direction
Notes
Bullet (only for penetrating wounds or for bullet fragments left behind in perforating wounds)
Clothing
Shotgun wounds
Injuries, external and internal
Entrance wound
Modifications
Track
Exit wound/site of lodgment
Course and direction
Notes
Clothing
Blunt force trauma template
Injuries, external and internal
Notes
Sharp force trauma templates
Injuries, external and internal
Notes
Incised wounds
Notes
Injuries, external and internal
Notes
Hanging template
Injuries, external and internal
Thermal burn injury template
Injuries, external and internal
D - Library for forensic pathology fellows
References
E - Hirschisms and Adelsonisms
. Hirschisms
. Adelsonisms
References
Index
A
B
C
D
E
F
G
H
I
K
L
M
N
O
P
Q
R
S
T
U
V
W
Y
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