Forensic Pathology First Quiz

Sept. 25th

Forensic Pathology:

A branch of forensics that examines death and the investigation of the body

Egyptians:

 first of the removal of organs

• Religious reasons

• Remove the heart and weigh it to the feather or truth

Autopsy:

•  derives from the Ancient Greek

• “To see for oneself”

• “Sight, view”

• Around 3000 BC, ancient Egyptians were one of the first civilizations to practice the removal and examination of the internal organs of humans.

  • More for religious reasons and not so much to determine the cause of death

In 44 B.C., Julius Caesar was stabbed to death by at least 60 rival senatorCaesar’s’s personal physician, Antistius, performed an autopsy and issued an official “autopsy report” (the first in history”

• He found that Caesar had been stabbed 23 times. None was fatal except the second wound in the breast, which pierced his aorta. a

• This was declared a fatal wound, although it was noted that the amount of blood loss from the other wounds would also have been fatal. Al.

• Antistius delivered his results to a Roman forum (the first expert witness), leading to the development of the term “forensic,” meaning “before the forum.”

1888:

•  in the London area known as White Chapel, five women were brutally murdered and mutilated

Jack the Ripper’s social media campaign

• “Dear Boss” letter was postmarked and received on 27 September 1888 by the Central News Agency of London and forwarded to Scotland Yard.d

• Taunting police

• Some feel that the letters were a hoax perpetrated by a local journalist to sell newspapers.s

• Yet, the legend of the Ripper taunting the police has held on

• The name “Jack the Ripper” comes from these letters

• Media attention

Luka Magnotta:

• Born Eric Clinton Kirk New, July 24, 1982, in Canada

• Appeared in multiple pornographic videos and worked as a stripper and male model

• Was a pin-up model in a 2005 issue of Toronto’s “fab” magazine

• OUTtv’s readily show COVERguy

• Many claims about his personal life and celebrity, including being involved with Karla Homolka

• Initially came to the attention of law enforcement for uploading videos of himself killing a kitten

1 Lunatic 1 Icepick

• On May 25, 2012, an 11-minute video titled 1 Lunatic 1 Ice Pick was uploaded to a best gore website, depicting a naked male tied to a bed frame being repeatedly stabbed with an ice pick and a kitchen knife, then dismembered, followed by acts of necrophilia

• Body parts were sent to the Conservative Party of Canada, the Liberal Party of Canada, and an elementary school.

• The body was identified as that of Lib Jun, a Chinese international student.

• Magnotta was identified from surveillance video showing him disposing of the body part.s

• Apprehended at an Internet cafe in Berlin while reading news about himself in June 2012

• Convicted of first-degree murder on December 23, 2014

The public receives exposure to death and autopsy largely through the media and pop culture.

• Sex and death have always been the biggest sellers of media outlets

• One could argue that as sex becomes more mainstream, death is now the biggest seller

• The death of a famous celebrity frequently gets prominent media attention

• This is even more so if the death is felt to be “unnatural” or the result of some foul play

• The autopsy report garners great interest

• Conspiracy theory is rife

True Crime:

• Public interest in “True Crime”

• TV shows

• Books

• Documentaries

• Podcasts

• “in these fictional programs, sexy, charismatic, and highly astute crime scene investigators recover covert evidence from the crime scene, analyze the evidence with exceedingly sophisticated scientific testing procedures (often to the beat of a stylish soundtrack), make absolute conclusions about the perpetrator’s identity and involvement in the crime, and often extract a confession from the perpetrator, all within an hour”

2006 Nielsen Rating

• 30 million people watched CSI on one night

• 70 million people watched at least one of the CSI shows

• 40 million people watched one of two other forensic dramas: Without a Trace and Cold Case

• 5 of the top 10 television programs were about scientific evidence in a criminal trial

The “CSI effect”

• Portrayal of forensic science (especially on TV) influences public perception and ideas.

• More people are interested in forensic careers.

• Some studies implied that jurors expected more from forensic evidence, and the burden of proof placed on the prosecution was higher.r 

• Criminals could “get ideas”

• Police investigations 

What does the CSI effect mean for courtrooms?

• Do jurors expect more from forensic science

• Are they more likely to convict or acquit?

Shelton et al. 2007

• Study at Eastern Michigan University

• Presented potential jurors with various scenarios regarding differing levels of forensic evidence in different cases

• These higher expectations of having forensic evidence did not have an effect on the chance of conviction..

• The CSI effect doesn’t have a real-life effect on juries.

Julianna Redding:

• On March 16, 2008, 21-year-old Julianna Redding was discovered deceased in her Santa Monica, CA apartment.

• She had been beaten to death

• The smell of natural gas pervaded the apartment

• A lit candle was discovered burning on the coffee table

• Ms. Redding was a transplant from Arizona who had come to California to try to break into the movie industry

• She had appeared in several ads, both print and on television

• She was working as a hostess at a local restaurant

• It was there that it is theorized she met Dr. Munir Uwaydah

• Dr. Munirn Uwaydah was a surgeon who operated multiple clinics in the Los Angeles and Santa Monica area

• He was reportedly a multimillionaire

• He hired Ms. Redding to work in one of his clinics, and he presented her with a lavish gift.s

• There is evidence that they had a romantic relationship

• Dr. Uwaydah also pursued Greg Redding, Ms. Redding’s father, who was a pharmacist

• Greg Redding backed out of a supposed business deal after hearing rumors of Uwaydah’s shady business deals and discovering that Uwaydah was married with several children overseas

• Five days later, Julianna Redding was found dead

• No forced entry

• A neighbor reported hearing screams around 9:53 on March 15th

• An aborted call to 911 was placed around 9:53

• Ms. Redding had been strangled to death, and defensive wounds were identified on her throat.

• A large amount of DNA was detected at the current scene

  • On the victim's skin, clothes, and cell phone

  • On the stove knob

  • A bloody fingerprint was found on a plate in the sink

• All of the DNA at the crime scene (as well as the fingerprint) belonged to a woman named Kelly Soo Park

• Kelly was employed by Uwaydah

• Many assert that she was an “enforcer” for Uwaydah, but this was not admitted at trial

• The defense claimed that her DNA had been deposited by secondary transfer

• Secondary transfer occurred because Julianna was taking paper towels from the job to clean her house, and Kelly was the one supplying the paper towels in the job

• After three hours, the jury acquitted Kelly Soo Park for the murder of Julianna Redding

• As it turns out:

  • The defense used a “jury profiler”

  • Potential jurors were questioned about their television-watching habits

  • Jurors were preferentially selected based on those who preferred television shows that favored the defense and defendants.

Don’t be fooled by the DNA

• Lee Miles

  • Trial partners

• Our biggest challenge is that for most people, DNA is DNA, and it tells the truth. Everybody gets that from TV.”

• “We were only allowed twenty minutes to question the prospective jurors, so I felt that I had to rely on as much of the art of what I do as the science.”

• “I’m looking for, sometimes, a contrarian. Someone who, no matter what you say, they’re going to start challenging you.”

• “Probably our most favorite juror, who ended up being the foreperson, one of his favorite shows was The Good Wife. They’re openly confronting the fact that they are often working for clients that they think look guilty, and yet they give them the very best defense possible.”

• “Criminal Minds and Blue Bloods, if those were a juror's favorite show, they might be more prosecution-oriented oriented”

• “The verdict really showed that DNA alone is not enough to convict someone.”

Medical Examiners interrogate suspects:

No. They do work closely with the police and investigators to obtain information.

Time of death is an exact science:

• Time of death is very hard to determine, and no method is foolproof

• Liver temperature can be affected by many things

• Vitreous fluid

• General determinations can be made, but “the patient died between 7 and 7:15 am” isn’t really a thing (unless the bullet also broke a clock)

Technology:

• Most labs are in the state budget

• A lot of the technology you see on TV doesn’t actually exist

• Usually no windows in the morgue either

DNA is analyzed in ten minutes

• Another big NCIS offender

• DNA analysis is painstaking work and can take weeks

• Many labs are backlogged and can take months to issue a report

• Many forensic pathologists do not have a DNA lab on-site

Only involved with murders

• Actually, most cases that involve forensic pathology are not murders or suicides.

• Many more natural and accidental deaths

• These cases can also require the skills of a forensic team to determine the cause and circumstances of death.

Careers in Forensics

• Medical Examiner

  • Job Description

    • Perform autopsy, investigate cause and manner of death, testify in court

  • Education

    • Medical degree (MD)

    • Pathologist, residency in Anatomic Pathology

    • Fellowship in forensic pathology

    • Board-certified by the American Board of Pathology in Forensic Pathology

    • 9 years post-graduate education

  • Average salary

    • $200,000

• Coroner:

  • Job description

    • Investigate cause and manner of death, may perform autopsy, may testify in court

  • Education

    • No definitive education required

    • Elected public office

  • Average salary

    • $70,000

• Pathologist Assistant:

  • Job Description

    • Eviscerate during autopsy, write preliminary report, perform surgical pathology duties (grossing, etc)

  • Education

    • Graduation from a national accrediting agency for clinical laboratory sciences (NAACLS) accredited education program

    • Successfully passing the American Society for Clinical Pathology (ASCP) certification exam

  • Average salary

    • $100,000

• Diener

  • Job description

    • Eviscerate during autopsy

  • Education

    • High school diploma or associate's degreeOn-the-jobb training

  • Average salary

    • $35,000

• Forensic Investigator

  • Job description

    • Go to the scene, preliminary investigation, interview, and work closely with the medical examiner

    • Brief the medical examiner on use

  • Education

    • Usually a bachelor's or an associate's degree

    • Degree in a forensic-related field preferred

    • Knowledge of the manner and cause of death

    • On-the-job training

  • Average salary

    • $50,000

• Crime Scene Technician

  • Job description

    • Go to the scene, collect evidence

    • Work closely with the police and the office of Forensic Science

  • Education

    • Usually a bachelor's or an associate's degree

    • Degree in a forensic-related field preferred

    • Knowledge of the manner and cause of death

    • On-the-job training

  • Average salary

    • $50,000

3 American serial killers are generally considered to have more than 30 victims.

• Ted Bundy

  • American serial killer known for his charisma and good looks

  • Confessed to 30 homicides, but has confessed to killing 35-36 women in the past, and some estimates run upwards of 100 or more

  • Infamous for escaping from prison twice and murdering multiple victims in one day, sometimes abducting women from the same location within hours of one another

  • He was executed in the electric chair in 1989

• John Wayne Gacy

  • Known to have murdered a minimum of 33 teenage boys and young men between 1972 and 1978, 26 of whom he buried in the crawl space of his Chicago home

  • Gacy was known as the “Killer Clown” due to the fact that he often entertained children at social events dressed in a self-devised clown costume.

  • Gacy was executed in 1994

• Gary Ridgeway

  • Also known as The Green River Killer

  • Truck painter who confessed to killing 71 women

  • Almost exclusively targeted sex workers from Seattle

  • Suspected of killing over 90 victims, confessed to 7, convicted of 49

  • Sentenced to life without parole

Forensic Pathology

• The BA branch of pathology that applies medical knowledge to the court of law

• Forensic pathologists are physicians (MD, DO) who are trained in pathology and specialize in forensics

  • Perform medicolegal autopsies

  • Issue the death certificate and report

    • Cause and manner of death

  • Offer expert opinion in court

Team members

• Forensic pathologists

• Investigators

• Autopsy technicians

• Toxicologists

• DNA lab

• Anthropologists

• Forensic dentist

Forensic autopsy

• Examination of a dead body to determine the cause and manner of death

• Identity needs to be established

• Cases of sudden, unexplained, suspicious, or violent death

• Delaware code title 29, chapter 47

How does the ME office get involved?

• Death is reported by:

  • Hospitals, mostly ER

  • Police

  • Nursing homes

  • Hospice

  • Correctional facilities

  • Fire Marshal's office

  • Gift of Life

  • Attorney General's Office

• Skins, bones, cornea

• Bones: Material will be used for replacement

• Skin will go to burn victims

• Cornea

• Who needs a forensic autopsy?

Person dies → police (other) → suspected foul play (csi, detectives, AG) → ME, autopsy performed.

• You have to be careful when issuing the time of death

Disposition of cases: Natural Death

• Inquiry:

  • No doctor to sign DC

  • Extensive medical problems

• Released from the scene due to extensive medical problems

• Inspection (external examination)

  • Elderly, with no doctor

• Autopsy: 

  • Descendants with no known medical problems

Scene Investigation

• The most important part of the investigation

• Crucial to be observant of small details

  • Does anything look out of place?

  • Suspicious circumstances

  • Staged scene, postmortem manipulation

  • Signs of forced entry

  • Drug paraphernalia

• Death investigators/ME have jurisdiction over the body, and law enforcement has jurisdiction over the scene.e

  • Professionalism and good interdepartmental communication are key

Death scene investigation

• Forensic investigator goes to the scene (depending on the case and state)

  • Investigators must wear protective equipment (shoe covers, mask, gloves, etc.)

  • Scene and body must be photographed

  • Conducts interviews of family, friends, witnesses

  • Transports the body to the morgue

• Obtains medical information

• Maintains close contact with the police if needed

  • N.b,. policdepartmentpt, all of the scene investigation in homicides

    • Collect evidence (e, weapons, bullets, blood, fingerprints, etc.)

• Scenes must be attended (pathologist or forensic investigator) in homicides, suspected homicides, mass fatalities, and all pediatric deaths.

• Positions of the  body are not described in relation to nearby objects, presence of weapons, blood spatter, wounds (if visible), suicide note(s), medications

• The body is placed in a body bag, which is sealed to maintain the chain of custody.

• The scene may be visited or revisited after an autopsy is performed if new information is unearthed.d

• Requires police presence

• The report about the scene investigation needs to be completed promptly:

  • Where, when, who reported, when arrived at scene, circumstances, medical history, medications, scene description, disposition of the body

Examination of clothing

• Needs to be examined at the scene and during autopsy

• Examine for blood, semen, and other body fluids

• Check pockets for personal belongings, drug/paraphernalia, medications

• Injuries should match damage to the clothing (cuts, holes from a  gunshot wound)

• Tearing, grease marks, broken glass, and paint chips can assist in reconstruction for a motor vehicle accident

Determining CoD and MoD

• 42-year-old female, history of alcohol abuse, found dead at the bottom of the steps

  • Interview of neighbors: allegedly involved in an altercation the previous night

  • Medical records reveal an ER visit for a broken nose and laceration repair on the cheek 2 months ago

  • On autopsy: numerous bruises, head trauma, and cirrhotic liver30-year-oldd male, history of depression, found at his residence, numerous pill bottles with missing pills. On the day found was the first anniversary of his mother's death

  • No foul play at the scene

  • Autopsy: negative findings

  • Toxicology positive for zoloft, Benadryl, Tylenol

• 25-year-old female, found dead by her friend, heroin packets at the scene, tourniquet on the arm

  • Family reports several rehab admissions in the last 2 years and an abusive boyfriend

  • Autopsy reveals scattered bruises, but no severe trauma

  • Toxicology positive for heroin metabolites

• 65 year 65-year-old male with dementia and chronic pain was found dead in bed, with numerous opened pill bottles

  • Lives by himself, has a caretaker who comes every day

  • Autopsy: negative findings, no trauma

  • Toxicology: high levels of antidepressants and oxycodone

  • Identification of the body

    • Known:

      • Family identifies the body

      • Documents (ex: drivers license)

    • Unknown:

      • No family/identification documents

      • Due to decomposition/skeleton remains

      • Missing person

      • Found in remote area

      • Burned or mutilated bodies

Identification of the Body

• Known

  • Family identifies the body

  • Documents, e.g, driver's license

• Unknown

  • No family/identification documents

  • Due to decomposition/skeletal remains

  • Missing person

  • Found an iemote area

  • Burned or mutilated bodies

Postmortem interval (PMI)

• Time elapsed since death

  • Livor mortis

  • Rigor mortis

  • Core body temperature

  • Degree of decomposition

  • Insect activity

  • Animal activity

  • Scene investigation

Lividity

• Reddish-purple discoloration in dependent areas of the body due to gravity

• Areas resting against a firm surface will be pale

• Evidence within 30 minutes to 2 hours after death

  • Not fixed

• Reaches a maximum of 8-12 hr

  • Fixed

• Not helpful for PMI, but to determine if the body was moved

Rigor Mortis

• Stiffening of muscles due to the disappearance of the metabolic energy source within cells (ATP) and the accumulation of lactic acid

• Appears 3-6 hr after death, fully developed by 12 hr

  • First in small muscles: face, jaw

• May last 18-36 hr

• Influenced by

  • Activity before death

  • Temperature

  • Clothing

  • Preexisting conditions

• Rapid:

  • Heavy exercise

  • Seizures

  • fever/infection

  • Poisons

    • Strychnine

  • Electrocution

• Delayed:

  • Cold temperature

  • Thin

  • Chronic disease

Temperature

• PMI = 37 degree celsius - rectal temp + 3 degree celsius

• Imperfect

  • The environment around the body

  • Cooling not uniform

  • AC or heating

  • Wet, dry conditions

  • Sun, shade

  • Extremes of age

Other techniques

• Vitreous fluid potassium levels

• Gastric emptying

  • Invalidated

    • Types of food, protein vs fatty meal

    • Affected by comorbid conditions, ex, diabetes

Death Scene Investigation

• These clues are the most helpful in determining PMI if the person was not seen for an extended period of time.

  • Bank activity

  • Unopened mail

  • Missed appointments

  • Receipts

  • Text messages, phone calls, emails

  • Social media

Postmortem Changes

• Autolysis

  • Self-digestion of cells due to enzymes

• Putrefaction

  • Breakdown of tissue due to anaerobic bacterial activity intestines

• Influenced primarily by moisture and temperature

Decomposition

• A corpse progresses through five stages of decomposition

  • Fresh

  • Bloat (autolysis)

  • Active decay (putrefaction)

  • Advanced decay

  • Skeletonisation

• Manifestations of decomposition

  • Marbling

    • Due to the breakdown of hemoglobin within blood vessels

  • Skin slippage and blistering

  • Green discoloration

  • Gas formation

  • Scrotal swelling

  • Maggot infestation

  • insect/animal activity

• Can occur rapidly, <24hr in hot climates

• The degree of decomposition may help to establish

  • Post mortem interval

  • Place of death

• To help advance this research, several body farms have been established

Mummification

• Body dehydrated

• Often, a dry and hot environment

Adiopcere

• Gray, whit, waxy material from the breakdown of fat to acids

• Body immersed in water or in a damp, warm environment

• Months to appear

Body Farm

• Bill Bass established the Forensic Anthropology Center in 1987

• Observe body decomposition in different conditions for training and medicolegal purposes

• Bodies donated to medicine

  • 4000 registered future donors

Entomology

• Studying the mature flies, pupal casings and maggots can help determine PMI

• Correlated against weather patterns

• Each state of decomposition attracts a different species of insect

Identification

• Fingerprints are the fastest way to identify

  • Although it is hard because not everybody’s fingerprints are in a system

• Tattoo

• Surgery scars

• Dental

• DNA

• Medical equipment

Skeletal Remains

• Requires consultation of a forensic anthropologist

• Determine sex, age, stature, race

  • PMI estimation is difficult

• DNA

Forensic anthropology

• Helps to determine if there was pre-, peri, post post-mortem trauma

• Helps to identify if the deceased had a predisposing joint/bone disease

• Help to determine if the deceased had procedures/surgeries with implants

External Examination

• X-ray

  • Performed on cases with gunshot wounds, sharp force injuries, and pediatric death

  • Localizes and identifies the presence of metal objects

  • Identifies bone fractures

  • Also may be used for ID purposes

• UV light

• Evidence collection

• Photography

• Examination of clothing

• Documentation

• Washing

• Photography

Tardieu spots

Small hemorrhages due to rupture of small vessels

Postmortem drying of sclera

Collection of rape kit

• Fingernail scrapings

• Vaginal swab

• Oral swab

• Rectal swab

• Pubic hair

• Head hair

• Underwear

Rape kit

• Two cotton tip swabs used for collection of vaginal, oral, and rectal specimens

  • Smears on glass slides and then air-dried

  • Slides are stained to identify sperm

  • Failure to demonstrate sperm does not preclude intercourse

Evidence Collection

• In cases of homicide and suspicious death, the body has to be examined for trace evidence

  • Hair

  • Fibers

  • Paint

  • Foreign material

• Labeled, sealed, and submitted to police, maintaining the chain of custody

Bite marks

• Should be swabbed for recovery of saliva for DNA testing

• Forensic dentist consultation

Internal Exam

• An essential part of autopsy

  • Requires knowledge of anatomy and pathology

• Examination of all internal organs

• Different pathological conditions can be diagnosed during gross exam

  • Congenital anomalies

  • Trauma

  • Cancer 

  • Infection

• For centuries, internal examination was the only tool available to determine the cause of death

• Changes in organs lead to the discovery of pathological processes

• Most pathology books use knowledge of autopsy findings in diagnosing the disease

• In the 18th century, the idea of matching autopsy findings with pre-death diagnosis was introduced

• During the first half of the 20th century, postmortem examinations demonstrated that clinical diagnoses were often wrong

• Through autopsies, doctors were better able to understand and correct trends in misdiagnosis and to identify mistakes

• Autopsy was critical to improvement of joint prostheses, new heart valves, and heart transplants

• Y-shaped incision is performed

• Skin and soft tissue is reflected

• Chest plate is removed

• Examination of 3 cavities

  • Chest

    • Heart and lungs

  • Abdomen

    • Liver, spleen, kidneys, intestines, adrenal glands, pancreas

  • Cranial 

    • Brain

Methods of Examination

• Virchov’s: organ by organ

• Rokitansky: en block removal and dissection

• All organs are weighed, examined, and sections and cultures are taken if needed

• Scalp incised

• Skull cap removed

• Dura opened

• Brain removed and examined

• Small pieces of tissues are saved in formalin

  • Microscopic analysis

Chest Cavity

• Heart

• Lungs

• Thoracic aorta

• Rib cage

Heart

• Normally weighs 250-400 grams

• Pumps blood rich in oxygen to all organs

• Located inside pericardial sac

• Heart disease is leading cause of death

  • Myocardial infarction

  • Hypertension

  • Atherosclerosis

  • Aortic dissection

Sudden Cardiac Death

• May be due to atherosclerosis, ie, narrowing of coronary arteries due to cholesterol plaques

• Myocardial infarctions are more rare among forensic autopsies

  • Seen more in a hospital setting

• Mechanism is the sudden onset of ventricular fibrillation

• Often seen after strenuous physical or emotional activity eg, snow shoveling, grass cutting, running

Hypertension

• Can lead to cardiomegaly (enlarged heart) or left ventricular hypertrophy (thick left ventricle)

• Predisposes to sudden death due to

  • Ruptured aortic aneurysm

  • Sudden arrhythmia

  • Stroke

Lungs

• Paired, sponge-like organs

  • Right lung is larger

• Normally weigh 350-450 grams

• Oxygenate blood and eliminate carbon monoxide

• Damaged by tobacco smoke, leading to COPD

• Light and air filled in asthma

• Heavy and congested in heart disease

• Filled with fluid in drug overdose

• Pulmonary embolism

  • Blood clot in the pulmonary artery(ies) which occludes flow through lungs, cutting off oxygenated blood back to the heart

• Who is at risk?

  • Recent injury or surgery

  • Cancer

  • Contraceptive medications

  • Immobilization for a prolonged time

  • Genetic factors

• Can present as sudden death

Abdominal Cavity

• Liver

• Kidneys

• Stomach

• Intestines

• Spleen

• Pancreas

• Adrenal glands

Abdomen

• Ischemic bowel

• Peritonitis

• GI bleeding

• Cirrhosis

• Ruptured abdominal aneurysm

• Acute pancreatitis

• Spleen laceration with bleeding

Kidneys

• Paired, bean-shaped smooth surface organs

• Normally weigh 100-160 grams

• Filter waste products from blood and produce urine

• Regulate blood pressure and electrolyte balance

• Granular surface

  • Hypertension

• Small and atrophied

  • Diabetes

Liver

• Largest organ in the body

• Normally weighs 1200-1600g

• Primary function is to produce bile, break down fats, remove toxins, and produce proteins important for clotting

• Brown and smooth surface

• Alcohol abuse and hepatitis C are two common causes of liver failure due to cirrhosis

Spleen

• Located in the left upper quadrant of the abdomen

• It recycles red blood cells and plays an important role within the immune system by storing white blood cells

• Extremely rich blood supply

  • After trauma, it can lead to massive hemorrhage, causing hemoperitoneum (blood in abdominal cavity)

• Can be affected in viral infections

  • Mono

Stomach

• Acidic environment allows for first part of digestion, eg. the breakdown of food

• Stomach lining can be irritated by alcohol and tobacco, leading to ulcers, which can bleed

Intestines

• Small intestine: about 20 feet long

• Large intestines: about 5 feet long

• Digestion of food, absorption of nutrients and water, and production of waste

• Commonly found postmortem pathologies

  • cancer 

  • Diverticulitis

  • Ischemic bowel

  • Ruptured appendicitis 

Pancreas

• Produces enzymes to help digest fat

• Produces insulin, controls blood sugar

• Acute pancreatitis

  • Commonly seen with alcohol abuse

Cranial cavity

• The brain normally weighs 1200-1450 grams

• Very important for examinations in the cases of trauma, especially child abuse

• Can identify changes if meningitis or encephalitis

• Diagnoses of Alzheimer’s, Lewy Body dementia, etc., are made only postmortem

  • White matter shrinking

  • Amyloid plaques

Brain

• Controls all functions of the body

• Interprets information from the outside world

  • Hearing, smell, taste, touch, sight

  • Essence of mind and soul

• Intelligence, creativity, emotion, and memory are a few things governed by the brain

• 3 parts: cerebrum, brain stem, cerebellum

• Protected by dura and skull

Natural Death

• Sudden and unexpected

• Cardiovascular disease is the most common and leading cause in men

• Atherosclerosis

• Myocardial infarction

• Aortic dissection

• Stroke

• Ruptured cerebral aneurysm

• Diabetes mellitus, obesity, smoking, and ethanol abuse are important contributory factors to morbidity

• Medical history is essential

  • Recent ER/doctor’s visits

  • Review of prescription medications

Testing

• Preliminary: ELISA, detects commonly used and abused drugs

• Confirmatory: GC/MS, LC?MS

  • Will confirm and give concentrations

• Gas Chromatography

  • Separation of multiple compounds in a mixture appears as peaks

• Mass Spectroscopy

  • Detects the fingerprint of each compound

Drug Testing

• Hundreds of different drug compounds

  • Antidepressants

  • Antipsychotics

  • Stimulants

  • Pain killers

  • Sedatives

  • Tylenol

What is pathology?

• The study of disease

• Divided into anatomic pathology and clinical pathology

  • Anatomic pathology: cytology (cells), histology (tissues), autopsy

  • Clinical pathology: lab administration, blood bank, chemistry, hematology, molecular pathology, microbiology, urinalysis

Who are pathologists?

• Physicians trained in anatomic and/or clinical pathology

• We supervise medical laboratories and all lab tests performed in a hospital or clinic

• We diagnose diseases looking at cells and tissue under a microscope

• We perform hospital autopsies when requested by family members

What is forensic pathology?

• The medicolegal investigation of sudden, unexplained deaths, violent deaths, and suspicious deaths

• Forensic pathologists are anatomic pathologists additionally trained in special autopsy procedures, collection of evidence, toxicology, injury patterns, would ballistics, forensic serology and DNA

• Forensic pathologists testify as expert witnesses in courts of law

What does it take to become a forensic pathologist?

• Bachelor degree (4 years)

• Medical degree (4 years)

• Anatomic pathology (3 years) or anatomic and clinical pathology residency (4 years)

• Forensic pathology fellowship (1-2 years)

• All forensic pathologists are required to be board certified in anatomic pathology and forensic pathology at a minimum

Why investigate deaths?

• To identify the decedent

• To determine cause and manner of death

• To identify diseases or injuries pertinent to public health

• To provide closure to families

• To determine if a crime has been comitted, documentation of injuries, and collection of evidence

Coroner Systems

• An elected public official whose duty is to determine cause and manner of death

• Usually are not physicians and have no medical training

• Very minimal forensic training if any

• If autopsy is determined to be necessary, a physician or forensic pathologist will perform (non-physician coroners cannot perform autopsies)

• May have a conflict of interest if a funeral director, prosecurtor, or law eforcement officail

• No accreditation or standarization between jurisdictions

Medical Examiner Systems

• Employ physicians (usually board certified forensic pathologists) to investigate deaths and perform autopsies

• May be accredited by the National Association of Medical Examiners (NAME)

• Usually work independently of law enforcement to prevent bias

• Many offices are critically understaffed in 2022

• FP Shortages making national headlines

What is an autopsy?

• Comes from the Greek word autopsia which means “seen by oneself”

• Involves an external examination of a deceased individual, sometimes followed by an internal examination of the organs

• There are different types of autopsy

  • Hospital autopsy vs forensic autopsy

  • External exam only vs partial autopsy vs virtopsy vs full autopsy

Hospital Autopsy

• Perfomed by general pathologist

• Requires written permission from next of kin

• Is an educational tool

• Minimal external examination; focus is on internal examination and correlation of findings with clinical records

• Almost never involves examination of neck organs; no collection of evidence or toxicology

• Usually can only sign out manner of death as “natural”

Top 10 Causes of Death in the US (2019)

• Heart disease, cancer, unintentional injuries, chronic lower respitatory disease, stroke, alzheimer disease, diabetes, kidney disease, influenza and pneumonia, suicide

Accidental Death:

• Since 2011, unintential posioning (drug overdoses) have been the leading injury mortality, followed by motor vehicle accidents

• The rate of drug overdose deaths is increasing every year

• The rate of drug overdose deaths due to synthetic opioids (fentanyl, fentanyl analogs, and tramadol) increased by 45% between 2016 and 2017 and continues to increase every year since

• Overdoses due to cocaine and other psychostimulants has also been on the rise since 2012

• Although official data is not yet available, it is believed that 2020 was the worst year for drug overdoses and suicides in recent history due to the COVID pandemic

Death Certificates:

• There is no standard death certificate, each state has their own version

• However, most have the general appearance shown

• The death certificate is very important

  • The source for state and national mortality statistics

  • Is often required before burial or cremation

  • Required for insurance payouts

Medical certifier required fields

• Date and time of death

• Cause of death

• Manner of death

• Was case referred to ME?

• Was an autopsy performed?

• Did tobacco use contribute to death?

• Pregnancy status of females

• Injury section as applicable

• Certifier section with signature

Cause of Death

• Any injury or disease that produces a physiologic dereangment in the body that results in the death of the individual

• Examples:

  • Gunshot wound of the head

  • Myocardial infarction (heart attack)

  • Multiple blunt force injuries

  • Heroin overdose

  • Hanging

• Immediate COD: occurs just before death

• Intermediate COD: intervening steps

• Proximate COD: what started the whole process

• Examples: pericardial tamponade due to ruptured myocardial infarction due to atherosclerotic cardiovascular disease

• Contributing conditions: diabetes mellitus

• Multiple blunt force injuries due to motor vehicle collision

• Or, most forensic pathologists would just sign cause of death as “gunshot wound of the abdomen”

Undetermined Cause of Death

• Rarely, after complete investigation, autopsy, histology, and toxicology, the cause of death cannot be determined

• The presumed mechanism in these deaths is a physiologic process, such as a cardiac arrhythmia, that leaves no evidence at autopsy

  • Genetic testing is becoming more commonplace to assist in these deaths but is not standard at this time

Mechanism of Death:

• The physiologic derangement produced by the cause of death that results in death

• Many causes of death have similar mechanisms of death

• Should NOT be used on a death certificate

• Examples: 

  • Hemorrhage

  • Cardiac arrhythmia

  • Cardiopulmonary arrest → this is frequently used in appropriately on death certificates by untrained physicians

Manner of Death:

• Explains how the cause of death came about

• This is determined by investigation, not the autopsy

• Five options:

  • Natural

    • Due to solely or nearly totally to disease and/or the aging process

  • Accident

    • There is no evidence that the injury occurred with intent to harm or cause death

  • Suicide

    • An intentional, self-inflicted act committed to do self-harm or cause death of oneself

  • Homicide

    • Occurs when death results from an injury from a volitional act committed by another person to cause fear, harm, or death

    • Classification of death as “homicide” does not indicate or imply criminal intent

  • Undetermined 

    • Used when the information pointing to one manner of death is no more compelling than one or more other competing manners of death when all information is considered

    • Some juristions was “undetermined” as a standard manner of death in drug overdose deaths unless the intent of the deceased is known

    • Law enforcement often cannot close a case with an “Undetermined” manner

Pending Investigation:

• Is NOT an appropriate final manner of death but can be used when filling out the initial death certificate if the pathologist is waiting for further investigation and testing

• Death certificates signed out as “pending investigation” must be amended when final cause and manner of death is determined

Basic Rules in Determining Manner

• The time interval between the injury and death is of little relevance

• In delayed deaths, it is important to consider what previous disease process or injury led to an individual’s demise

• When death involves a combination of natural processes and external factors such as injury, preference is given to the non-natural manner of death

• Consequences of chonric substance abuse, such as alcoholic cirrhosis, alcohol withdrawal seizures, endocardities secondary to chronic IV drug abuse, and emphysema associated with smoking are signed out as “natural” as long as toxicology is negative for a toxic level of the substance

• Deaths directly due to the acute toxic effects of a drug or poison are typically classified as “accident”

• Russian Roulette is typically classified as “suicide” because the act of placing a loaded firearm to the head and pulling the trigger is inherently dangerous

• Motor vehicle fatalities are usually classified as “accident” even if the driver was impaired

  • Vehicles homicide is a legal term and not used by forensic pathologists

• Death due to toxic envenomization, such as spider bites, snake bite, and anaphylactic reactions to bee stings are usually classified as “accident”

• Deaths due to positional restraint or choke hold by law enforcement personnel are classified as “homicide”

• Deaths due to discharge of a weapon by another person are usually classified as “homicide” unless it can be demonstrated that the weapon discharged without anyone pulling a trigger 

• A 55 year old male complains of severe chest pain and goes to the ER. he is diagnosed with a myocardial infarction (heart attack) but dies despite treatment.

• What is the cause of death?

  • Myocardial infarction

• What is the manner of death?

  • manner

• Would this case require autopsy?

  • yes

• A 20 year old male athlete suddenly collapses and dies during footbal practice. Should this case be referred to a medical examiner? Autopsy shows hypertrophic cardiomyopathy (a genetic type of enlarged heart) and toxicology is negative. What is the manner of death?

• Yes shold be referred to a medical examiner.

• Autopsy findings: HCM, negative toxicology

• Manner of death: natural

• Going back to the previous scenario, suppose the autopsy is negative. Investigation reveals that a rectal temperature taken on scene showed a core temperature of 106 degrees Fahrenheit.

  • What is the cause of death now?

    • Hyperthermia (heat stroke)

  • What is the manner of death?

    • Accident 

• A 60 year old male is paraplegic due to being shot in the back at age 18. He requires daily bladder catheterization since he is unable to urinate. He dies of sepsis (blood infection) due to a urinary tract infection.

• What is the cause of death?

  • Sepsis due to urinary tract infection

• What is the manner of death?

  • homicide

• A 23 year old female is found death in an abndoned warehouse with drug paraphernalia. Toxicology shows a toxic level of fentanyl. 

• What is the cause of death?

  • Fentanyl 

• What is the manner of death?

  • accident

• A 75 year old female is found deceased at home near several empty bottles of prescription medications. Her husband recently passed away. A will and insurance documents are found near her body. Autopsy shows severe heart disease. Toxicology is positive for lethal levels of multiple medications

• What is the manner of death?

  • suicide

• A 19 year old male is found deceased on the parking lot adjacent to a 20-story building. He has no known medical history, did not leave a suicide note, and had no recent life stressors. Autopsy shows multiple blunt force injuries and a blood alcohol level of 0.32

• What is the cause of death?

  • Multiple blunt force injuries due to fall from height

• What is the manner of death?

  • accident