Lethal intoxications of medical staff with substances used in the profession – Presentation of a group of cases

Abstract

The access medical staff has to special drugs through the nature of the job can lead to undesirable situations (illicit consumption, abuse and addiction, accidental overdoses, suicide, homicide). We focus on identifying situations of lethal intoxication of the medical staff with substances used within the profession and we propose a forensic approach to these types of cases. We made a review of the literature using MEDLINE, EMBASE, Scopus, Cochrane and internet search data of deaths among nurses and doctors due to intoxication with special regime drugs used in the profession. Five cases of autopsies performed at INML “Mina Minovici” Bucharest and Ilfov Medical-Legal Service, Romania, are presented (a veterinarian, a nurse and three anesthesiologist doctors). A 27-year-old female, a veterinarian, was found dead in bed, in her apartment, next to a 10-mL syringe with an attached branch, containing 4 ml of transparent liquid. It's a case of intravenous self-administration of T61, with a suicidal intention. T61 is a solution used for animal euthanasia, a mixture of 3 substances: embutramide (opioid analgesic), mebezonium iodide (curare-compound) and tetracaine hydrochloride (local anesthetic). A 38-year-old man, a male nurse, was found dead in his home, surrounded by several empty containers of Fentanyl and Mialgin. A bag with partially empty containers of medicines was found in his car: Enalapril, Telmisartan, Mialgin, Diazepam, Fentanyl, Acupan (nefopan chloridate), Dormicum (Midazolam), syringes and needles, used, but also sealed. The cause of death was an acute intoxication with a cocktail medication (opioid analgesics and benzodiazepines), stolen from the workplace. A 37-year-old man, an anesthesiologist doctor, was found by a colleague, at 7.00 a.m, in the on call room of the hospital, at the end of his shift. The cause of death was the acute intoxication with morphine (0.448 μg/mL). A 34-year-old woman, anesthesiologist doctor, was found dead by her father, on the bathroom floor of her apartment. Next to the body were found: a 5 mL syringe with 3 mL liquid content and 2 ampoules of tramadol hydrochloride (Mabron). In the trash, there was an empty bottle of ketamine hydrochloride (Ketamidor, for veterinary use) and fragments of ampoules of Midazolam and Calypsol. More than 150 ampoules labeled with various substances used in anesthesia were found in the house. In the last period, the woman doctor was exhausted as she had been working both in the public and private system. Female, 51 years old, anesthesiologist doctor, known as a consumer of analgesic substances for about 3 years, was found dead at home by her husband, on the bedroom floor. Cause of death was acute pulmonary edema, the consequence of an acute intoxication with drugs (pethidine > 2/mL μg/mL and nordazepam 0.03 μg/mL). The paper analyzes all the findings: the on-site investigations (extremely important to gather information), the necropsy data and the results of the histopathological, toxicological, tanatochemical and serological examinations. The analytical methods currently used for highlighting and dosing the identified substances are also presented. Autopsy findings were nonspecific, except for the stigma of chronic injectable drug use. That is why an algorithm for step by step approaching these types of cases could be very useful in order not to go beyond the possibility of an acute drug intoxication of medical staff. Nurses and doctors are vulnerable to chemical dependence due to the high work-related stress associated with easy access to medicines. This must always be suspected by the forensic doctors when they perform an autopsy of a medical staff person and they must follow a special algorithm in such cases.