Fulton County Medical Examiner Research Articles

The Fulton County Medical Examiner's Experience With the Federal Bureau of Investigation National Missing Person DNA Database Program

Medical examiners and coroners occasionally encounter unidentified human bodies, which remain unidentified for extended periods. In such cases, when traditional methods of identification have failed or cannot be used, DNA profiling may be used. The Federal Bureau of Investigation has a National Missing Person DNA database (NMPDD) laboratory to which samples may be submitted on such cases and from possible relatives or environments of unidentified decedents. This article describes the experience of the Fulton County Medical Examiner (FCME) in submitting samples to the NMPDD laboratory. A database was established at the FCME to track the submission of samples from unidentified decedents to the NMPDD laboratory for DNA testing along with the results and turnaround times. In December 2004, the FCME inventoried all cases for which samples were available and began to submit them to the NMPDD laboratory for testing. DNA testing and isolation rates, sample type, and turnaround times were tabulated in October 2006 for samples submitted between December 16, 2004 and December 16, 2005. An overall summary of data was also prepared concerning the status of all samples submitted as of April 17, 2007. During the 1-year study period, samples from 77 unidentified decedents were submitted to the laboratory. As of October 2006 (22 months after submission of the first samples and 10 months after submission of the last samples), testing had been completed on 53% of the samples submitted, and 68% of those tested resulted in a mitochondrial DNA profile. Turnaround times ranged from 66 to 557 days, improved with time, and had a mean of 107 days for specimens submitted during the latter part of the study period. As of April 17, 2007, we had submitted samples involving 84 unidentified decedents. Seventy-five percent of the samples have now been tested. Data from the NMPDD laboratory have resulted in 4 identifications by comparison with putative relatives, 4 exclusions, and no cold hits through comparison NMPDD DNA profiles from missing persons. More extensive data are presented in the body of this article. The NMPDD laboratory provides useful and free services to medical examiners, coroners, and law enforcement agencies that require DNA services regarding missing and unidentified persons. Turnaround times have improved. The success of the system in getting cold hits will be heavily dependent on law enforcement filing missing persons reports and submission of reference samples from putative relatives of the decedent. We recommend collecting specimens for DNA analysis early on in the postmortem investigation, submitting samples to the NMPDD laboratory or one of its participating laboratories when traditional methods for identification cannot be used or have failed, not burying bodies until a DNA profile has been obtained, and not cremating unidentified remains.

A 10-year epidemiologic review of homicide cases in children younger than 5 years in Fulton County, GA: 1996-2005.

The primary purpose of this study was to present the epidemiologic review of homicide deaths certified by the Fulton County Medical Examiner's Office from January 1, 1996 through December 31, 2005 in children younger than 5 years. The secondary purpose of this study was to determine if the observed cases of homicide deaths among children younger than 5 years in Fulton County are significantly greater than expected when compared with those in the State of Georgia. For purposes of this study, only homicide deaths of Fulton County residents were included. The authors reviewed all homicide cases in children younger than 5 years: infancy (<1 year) and early childhood (1-4 years). χ values were calculated using Epi Info (version 3.4.1; Centers for Disease Control and Prevention, Atlanta, Ga) to determine differences in homicide among age group, race, and sex variables. In addition, a χ test at the α level of 0.05 was done to determine if the observed cases of homicide deaths among children younger than 5 years in Fulton County were significantly greater than expected when compared with those in the State of Georgia. There were 49 homicide cases in children younger than 5 years identified over this 10-year period. The yearly distribution of these 49 homicide deaths ranged from 1 death in 2003 to 9 deaths in 2004. Most of the patients were male (n=29, 59.2%) and black (n=44, 89.8%). Between infancy and early childhood cases, homicide victims were nearly equally divided between the 2 groups. However, χ values showed that decedents younger than 5 years are more likely to have died of homicide compared with decedents 5 years or older (odds ratio [OR], 1.74; 95% confidence interval [CI], 1.29-2.35). Black decedents younger than 5 years are more likely to have died of homicide compared with other races (OR, 3.21; 95% CI, 1.21-9.28). Male and female decedents are equally at risk to have died of homicide (OR, 1.14; 95% CI, 0.61-2.11). The authors also determined that the total homicide risk for children younger than 5 years in Fulton County during the years 1996 to 2005, at the α level of 0.05, is 1.8 relative to the state. Brain injury was the primary cause of death in most cases (n=23, 46.9%). Although this study was unable to collect information on the victim's suspect/offender characteristics, it was noted that only 37% of the cases (n=18) went to trial. Most homicide investigations were under the Atlanta police jurisdiction (n=28, 57.1%). Results from this study may assist local and state government officials in recognizing the epidemiologic characteristics of children at risk to help them allocate limited resources efficiently and implement preventive measures to at-risk populations effectively.

Postmortem Blood Cadmium, Lead, and Mercury Concentrations: Comparisons with Regard to Sampling Location and Reference Ranges for Living Persons

This study's goal was to determine cadmium (Cd), lead (Pb), total mercury (THg), and inorganic mercury (IHg) levels in human cadavers to compare measured levels with established reference ranges for living persons and to determine whether blood levels varied with time from death to sample collection or by body collection site. Subjects (n = 66) recruited from the Fulton County Medical Examiner's Office in Atlanta, GA, were 20 years of age or older, had no penetrating trauma, no obvious source of environmental contamination of the vasculature, and had whole blood accessible from the femoral (F) site, the cardiac (C) site, or both. Geometric mean results were as follows: 2.59 microg/L F-Cd; 11.81 microg/L C-Cd; 1.03 microg/L F-THg; 2.01 microg/L C-THg; 0.29 microg/L F-IHg; 0.49 microg/L C-IHg; 1.78 microg/dL F-Pb; and 1.87 microg/dL C-Pb. Both F- and C-Cd levels as well as C-THg levels were significantly higher than reference values among living persons (C- and F-Cd, p < 0.0001 and C-THg, p = 0.0001, respectively). Based on regression modeling, as the postmortem interval increased, blood Cd levels increased (p < 0.006). Postmortem blood Cd concentrations were elevated compared to population values and varied with respect to sampling location and postmortem interval.

Accidental drug deaths in Fulton County, Georgia, 2002: characteristics, case management and certification issues.

Historically, the duty of the medical examiner in assigning cause and manner of death in drug-related death cases has been fraught with controversial challenges. The lack of standardization in certifying drug-related deaths may involve differences among practicing forensic pathologists in their approach to such cases. The central objectives of the present study include characterization of current drug death patterns and the variability among medical examiners with respect to autopsy performance and death certification practices in one county medical examiner's office. Death certificates, scene information/investigative reports, autopsy reports, and toxicological laboratory results for each of the 100 cases of drug-related death occurring in 2002 in Fulton County, Georgia were reviewed. Comparison of overall autopsy rates and autopsy rates in drug-related death cases for each medical examiner individually and for the group collectively was performed. In examining cocaine-related deaths (most common), statistical analysis was performed for comparison of drug concentrations (cocaine and benzoylecgonine) between deaths certified as cocaine toxicity (poisoning) versus cocaine-complicating disease or causing an adverse event such as cerebral hemorrhage. Causes of accidental drug deaths included cocaine 40%, mixed drug intoxication 37%, opioids 10%, ethanol 7%, and prescription medication (nonopioid) 5%. Overall total autopsy rates in 2002 for each of the 6 independent medical examiners ranged from 51% to 69% (mean 64%), whereas autopsy rates in drug-related death ranged from 55% to 91% (mean 81%). In review of the subset of 40 cocaine-related deaths, 25% were certified as cocaine toxicity (poisoning), with the remaining 75% certified as cocaine-complicating disease or causing and adverse event. Autopsy rates in cocaine-related deaths were as follows: cocaine toxicity 80%, cocaine-complicating disease 77.3%, and cocaine causing adverse event 62.5%. Thirty-eight percent of cocaine-related deaths were considered to be of "low suspicion" for drug involvement at the time the death was reported to the medical examiner with the remaining 62% being of "high suspicion". Autopsy rates were somewhat lower in the low suspicion group (67%) versus the high suspicion group (72%). Comparison of drug levels between cocaine-related death certification groups was performed. No statistically significant difference was shown in drug levels (cocaine, P > 0.3; benzoylecgonine, P > 0.2) between deaths certified as cocaine toxicity versus those certified as cocaine-complicating disease or causing adverse event. In Fulton County, accidental drug deaths in 2002 most often involved cocaine either alone or in combination with opiates and/or alcohol. Cocaine, opiates, or both were involved in greater than three-fourths (77%) of all drug-related deaths. The majority of all decedents were black (57%) and male (76%) with an average age of 42.2 years. Cocaine and ethanol were more frequently detected in black decedents, whereas opiates and polydrug abuse were more common in white decedents throughout the period studied. Preliminary investigation showed a high index of suspicion for the specific drug involved in virtually all opiate and alcohol cases, and in 62% of cocaine-related cases. Overall, the 100 accidental drug deaths in 2002 accounted for 7.5% of all deaths investigated and certified by the Fulton County Medical Examiner's Office. Our study provides further evidence to support the lack of correlation between serum drug levels and the mechanism of drug toxicity in cocaine-related deaths. No statistically significant differences were shown in parent cocaine or benzoylecgonine concentrations between those cases certified as toxicities or poisonings versus those cases certified as aggravating underlying disease or causing an adverse event. In addition, 62% of the cocaine-related death cases were considered initially to be of high suspicion for drug-related death, thus emphasizing the strong importance of scene information/investigative reports in evaluating drug-death cases and in formulating plans of action to handle each individual case. Among the drug-death cases handled by 6 staff medical examiners at the Fulton County Medical Examiner's Office, variation existed in autopsy performance and death certification practices. These issues are discussed in the context of the National Association of Medical Examiners' (NAME) Position Paper on Cocaine, NAME Forensic Autopsy Performance Standards, and other relevant literature. Most variations relate to completeness of the cause-of-death statement (whether or not comorbid conditions are included) rather than classification of manner of death within the office. However, specific wording in the cause of death may have significant ramifications regarding drug-related mortality statistics processed by the vital statistics system, with possible under-representation of drug-related deaths in single-cause mortality data.

Characteristics of Black and White Suicide Decedents in Fulton County, Georgia, 1988–2002

We compared the prevalence of risk factors for Black and White suicide decedents in Fulton County, Georgia, from 1988-2002. We used data from the Fulton County Medical Examiner's Office to compile information on suicides that occurred in Fulton County between 1988 and 2002. We used the chi(2) test and logistic regression to identify associations between suicide risk factors and race. Black suicide decedents were more likely than White suicide decedents to be male (odds ratio [OR]=2.06; 95% confidence interval [CI]=1.38, 3.09), to be younger, (>or=24 y [OR = 4.74; 95% CI = 2.88, 7.81]; 25-34 y [OR = 2.79; 95% CI = 1.74, 4.47]; 35-44 y [OR = 1.86; 95% CI = 1.13, 3.07]), and to hurt others in a suicide (OR = 4.22; 95% CI = 1.60, 11.15) but less likely to report depression (OR=0.63; 95% CI=0.48, 0.83), to have a family history of suicide (OR=0.08; 95% CI=0.01, 0.61), or to leave a suicide note (OR=0.37; 95% CI=0.26, 0.52). Future research should consider that Black suicide decedents are less likely to report depression than White suicide decedents. This suicide risk difference is important when developing effective suicide prevention programs.

Nonnatural Deaths of Adolescents and Teenagers

Childhood deaths are carefully scrutinized by many different government agencies, fatality review panels, researchers, and other groups. Many such deaths, especially those that involve external causes such as injury and poisoning, are amenable to prevention. Characterizing the causes and circumstances of nonnatural childhood deaths may provide information that is useful for development of prevention strategies and programs. This is a retrospective review of all nonnatural deaths investigated and certified by the Fulton County Medical Examiner involving persons 10 to 19 years of age during the years 1985-2004, inclusive. Cases were identified by searching electronic death investigation files maintained during the study period. Demographic and circumstantial information were tabulated for homicides, suicides, motor-vehicle fatalities, and other accidental deaths, and crude death rates were calculated for each 5-year period during the study. During the 20 year period there were 961 nonnatural deaths among persons 10 to 19 years of age. Most deaths were due to homicide (48%) followed by motor-vehicle fatalities (30%), suicide (12%), and nontraffic accidental fatalities (10%). Black males had the highest death rates among the homicide, suicide, and nontraffic accidental deaths, although the rates for each of these were lower in the most recent 5 year period than the first 5-year period. The number of deaths increased in each category as age increased, and this observation was most marked for homicides and least marked for nontraffic accidental deaths. Firearms were involved in 88% of homicides and 61% of suicides. Most nontraffic accidental deaths were due to water-related accidents, followed by drug and/or alcohol toxicity, fire-related injuries, and accidental firearms injuries. Homicide accounts for almost half of all deaths among persons 10 to 19 years of age. Black males are at particularly high risk for nonnatural death in comparison with other race/sex groups, especially for homicide. If effective firearm fatality prevention strategies and programs could be implemented, data in this study suggests that such a measure alone could cut in half the nonnatural mortality rate in the 10 to 19 year age group in Fulton County. Although homicide and suicide rates have declined, there remains room for improvement in these areas, as is the case for traffic-related and other accidental fatalities.

Evaluation of Certifier Practices Regarding Alcohol-Related Deaths

Alcohol can contribute to various manners of death by acute intoxication that places a person at risk for fatal injury, acute fatal alcohol poisoning, or the various fatal complications of chronic abuse with or without superimposed acute intoxication. The reporting of alcohol use on the death certificate may vary with office policy or procedure, certifier judgment, and the timing of information received during investigation. To determine the number of deaths including mention of alcohol use in the investigative case file, the number of death certificates on which alcohol use is reported, the number of discrepancies between the 2, and the possible reasons for observed discrepancies. Retrospective case review of all deaths where alcohol use was mentioned in the investigative case file and/or on the death certificate for deaths investigated by the Fulton County Medical Examiner in Atlanta, Georgia, during a 1-year period between January 1, 2004, and December 31, 2004. Percentage of deaths with alcohol use reported on the death certificate, tabulation of where and how alcohol use is reported on the death certificate, and tabulation of the differences between the investigative case file and death certificate regarding alcohol's possible role in causing death. Among the 1324 deaths certified by the office, 105 (8%) had alcohol use reported on the death certificate. The majority (67%) of these cases were natural deaths. Sixty-nine (5%) deaths had mention of alcohol use in the investigative case notes but did not include it on the death certificate. Twenty-five (2%) deaths had mention of alcohol on the death certificate but did not have mention of it in the investigative case file based on our search criteria. However, subsequent review of additional case follow-up information disclosed a history of alcohol use or acute intoxication in each case. The data show that more natural deaths are considered to be directly caused by alcohol than other manners of death. For the unnatural manners of death (excluding acute alcohol poisoning), alcohol use is often viewed by medical examiners as an incidental, associated finding or risk factor surrounding the circumstances of death rather than being an actual cause of death. In such cases, alcohol use is often omitted from the death certificate. For deaths directly caused by alcohol, the proportion of cases involving possible underreporting or overreporting of alcohol involvement was relatively small and usually involved the omission of chronic alcohol use from the death certificate. Researchers need to be aware of potential limitations of death certificate data for studying alcohol-related deaths.

Nonhuman Remains and Relics Encountered by the Medical Examiner

Medical examiner and coroner offices occasionally respond to "death scenes" which, after investigation, are found to involve nonhuman remains or other relics not requiring further investigation or certification of death. This report describes such cases encountered by the Fulton County medical examiner during 2003 and 2004. The electronic database used by the office contains check boxes to indicate whether a reported case involved nonhuman remains or other relics, in which case the name of the "deceased" is listed as "nonhuman remains" by selecting those words from a pull-down menu. Subject cases were identified during the 2-year period by searching the database for any case in which one of the boxes was checked or in which the name of the deceased was listed as nonhuman. Four thousand five hundred fifty-four deaths were investigated during the 2-year period, and 23 cases (0.5%) involved nonhuman remains or relics. Thus, the observed rate was about 5 cases per 1000 death investigations. Nineteen cases involved nonhuman bones. One case involved 2 human fetuses that had been teaching specimens. The other 3 cases involved a nonhuman fetus, a large decomposing dog that had been wrapped and dumped in residential area, and a sheep heart found in a bag which was a medical teaching specimen. Nonhuman remains and other relics are uncommonly seen in death investigation work and usually involve nonhuman bones, although a small variety of other atypical cases present themselves occasionally. Knowledge of these types of encounters is helpful so that the "unexpected" may become more "expected" and office policy and procedures tailored accordingly to facilitate case management.

Identification of the Unidentified Deceased and Locating Next of Kin

Medical examiner and coroner offices may face difficulties in trying to achieve identification of deceased persons who are unidentified or in locating next of kin for deceased persons who have been identified. The Fulton County medical examiner (FCME) has an office web site which includes information about unidentified decedents and cases for which next of kin are being sought. Information about unidentified deceased and cases in need of next of kin has been posted on the FCME web site for 3 years and 1 year, respectively. FCME investigators and staff medical examiners were surveyed about the web site's usefulness for making identifications and locating next of kin. No cases were recalled in which the web site led to making an identification. Two cases were reported in which next of kin were located, and another case involved a missing person being ruled out as one of the decedents. The web site page is visited by agencies interested in missing and unidentified persons, and employees do find it useful for follow-up because information about all unidentified decedents is located and easily accessible, electronically, in a single location. Despite low yield in making identifications and locating next of kin, the UID web site is useful in some respects, and there is no compelling reason to discontinue its existence. It is proposed that UID pages on office web sites be divided into "hot" (less than 30 days, for example) and "warm" (31 days to 1 year, for example) cases and that cases older than a year be designated as "cold cases." It is conceivable that all unidentified deceased cases nationally could be placed on a single web site designed for such purposes, to remain in public access until identity is established and confirmed.

Identification of the Unidentified Deceased

Multiple methods may be employed in an attempt to identify deceased individuals who are unidentified when reported to the medical examiner or coroner. The success and turnaround times of various methods differ. To determine the number of deaths initially involving unidentified individuals, their demographics, the methods used and turnaround times for cases in which identification was successful and the portion of cases that remain unidentified for significant periods of time. Retrospective case review of all decedents who were initially unidentified when death was reported to the Fulton County Medical Examiner in Atlanta, Georgia, during a 1-year period between May 2003 and May 2004. Rate per 1000 deaths which involved an unidentified decedent, tabulation of methods used to make identifications, and rate of cases remaining unidentified. Of 2279 deaths reported to the office, 100 were originally unidentified, resulting in a rate of 44 unidentified decedents per 1000 deaths reported. Those who remained unidentified involved 6 cases, resulting in a "cold case" rate of 2.6 per 1000 deaths. Seventy-eight percent were identified within 2 days, and the most common successful methods were visual identification (52%) and fingerprints (31%). Dental (10%), x-ray (4%), and other methods (6%) were least commonly used. Of the 94 persons identified, all identifications occurred within 29 days. DNA procedures were not needed in most cases, and in the few cases where such tests were needed, results were either unavailable or failed to show a match with known samples. The majority of unidentified deceased individuals were identified within 2 days, with visual verification or fingerprints accounting for about 83% of methods successfully employed. The medical examiner noted a rate of 44 unidentified deceased persons per 1000 death reports, with an ultimate "cold case" (long-term unidentified) rate of about 2.6 cases per 1000 death reports. These data may be useful in developing office policy and procedure regarding the procedural and temporal aspects of investigations centered on achieving identification and making dispositions of unidentified deceased bodies.

Quality Assurance Review of Death Certificates

Although quality assurance programs for medical examiners are required by the National Association of Medical Examiners' Inspection and Accreditation Checklist, quality assurance programs specifically targeting death certificate completion have not been addressed. The Fulton County Medical Examiner, Atlanta, GA, has implemented a pilot quality assurance program for death certificate information, and this report contains information about 1 year's experience with the program. All death certificates are reviewed by the case medical examiner(s) and chief medical examiner prior to their release to funeral homes. Death certificates with errors are retained for quality assurance and review purposes, and needed corrections are made before death certificates are released. During a 1-year period, death certificates with errors were collected and then reviewed and tabulated by type of error. Between May 26, 2003, and May 25, 2004, the Fulton County Medical Examiner certified 1267 deaths. Of these, 47 (4%) were found to contain errors that were corrected and an additional 52 (4%) had been amended for various reasons. The most common errors were misspellings in causes of death or poor or incomplete wording in injury-related information. Forty-seven percent of errors involved omitted, incomplete, or incorrect information that was potentially significant. The most common reason for amended certificates was unexpected detection of acute intoxications among people with significant cardiovascular disease. Quality assurance review of death certificates can assist in preventing the release of death certificates with incomplete, erroneous, or omitted information and may also be useful as an educational forum regarding completion of the death certificate.

Gunshot wounds of the female breast: a risk for intra-abdominal injury.

We report the results of a clinical study of female patients sustaining gunshot wounds to a breast. Thirteen homicides were reviewed by the Fulton County Medical Examiner. A prospective series of patients treated by the Grady Memorial Hospital Trauma Service included eight additional cases. Ten (48%) of the combined series of 21 patients had significant intra-abdominal injury; of these, five (24%) had injuries confined to the abdomen as a result of a missile striking a breast. A wound pattern consisting of a superior breast entrance wound, an inferior breast exit wound, and an inframammary thoracoabdominal reentry wound was noted in five patients, four of whom had intra-abdominal injuries and three only intra-abdominal injuries. Careful examination for this wound pattern should alert the clinician to the possibility of intra-abdominal injury. One should anticipate a 50% incidence of intra-abdominal injury in female patients sustaining gunshot wounds to a breast.