National Association Of Medical Examiners Research Articles

What is toxic in infants and children?

Postmortem toxicology in adults is a problem area: what then in infants and children? When an infant or a young child dies, drugs are seldom found to be the cause of death. But is this because we are not looking for an adequate panel of substances, or is it because we are not able to interpret our findings? Sudden infant death syndrome is a diagnosis of exclusion, and a toxicological examination is therefore mandatory in order to rule out poisoning/drug intoxication as a cause of death [1]. From previous studies it seems that positive drug findings are detected in as many as 25 % of all sudden unexpected deaths in infancy [2–4], but what do these findings mean; what do we actually know about toxic and lethal drug concentrations in infants and children; and are infants and children pharmacologically different from adults? These questions need to be answered in order to able to interpret the concentrations of drugs and poisons that are detected in postmortem blood samples collected from infant and early childhood deaths. First of all, what do we know about drug concentration levels in the pediatric population? There are very few previous publications on toxicological findings among pediatric deaths [5, 6], and often such publications to not include drug concentration levels. Because of a large number of different drugs, and the low number of drugs detected in this population, the gathering of data from a large number of deaths will be necessary to gain sufficient experience with pediatric drug concentration levels. A pediatric toxicology registry, based upon case submission, was established in the USA in 1985 through the National Association of Medical Examiners [7]. The registry’s purpose was to address questions such as: what drugs and poisons are most often observed among diseased children, what concentrations can be considered therapeutic, nonlethal or lethal, and how does growth and development pertain to drug concentrations in children. However, only a few studies have been published on the data from the registry [8]. Some publications on individual drugs and case reports exist, but all in all, little information is available on drug concentrations from pediatric deaths. Children are, however, commonly exposed to different drugs and poisons, as observed through toxicological surveillance in different countries [9, 10]. However, most childhood drug exposures are survived, and many do not require hospitalization [10]. Even if a child is hospitalized, toxicological screening is often not performed, with patients being treated symptomatically or on the suspicion of the drug ingested [11]. If drug testing has in fact been performed, this is often based on drug identification in urine alone, and not on drug quantification in serum/blood [12]. Many publications on pediatric drug exposures therefore do not include concentration levels of drugs of possible interest that could have offered helpful information regarding toxic levels in infants and children. Therapeutic monitoring of drugs used in the pediatric population is likewise seldom performed [13]. Therefore, it may be concluded that information on therapeutic, toxic and lethal drug concentration levels among infants and children is scarce and limited. The question then becomes, is the data collected from adults of any relevance or use in regards to children? In many regards infants and young children are not small adults [14]. Several factors can influence the metabolism of drugs in this population, such as physiological factors, the M. Arnestad (&) Division of Forensic Medicine and Drug Abuse Research, Department of Toxicological and Pharmacological Assessment, The Norwegian Institute of Public Health, PO Box 4404, Nydalen, 0403 Oslo, Norway e-mail: marianne.arnestad@fhi.no

Death Certification - Revisiting the Primary CDC and Name Literature

Death certification is performed by clinical physicians, physician medical examiners, and coroners. Some states also permit certification by nurses and physician assistants. The certifier enters specific disease and/or injury information on the death certificate to summarize the medical process(es) that culminated in death. These data condense a decedent's significant medical history and, in aggregate, present a year-to-year (or longer) view of disease and injury prevalence in the United States. The United States Centers for Disease Control and Prevention (CDC) is the umbrella organization that collects and processes all death certificate data. CDC publications are considered the primary guiding literature for completion of the medical portion of a death certificate; an expanded discussion of manner of death is provided by a National Association of Medical Examiners (NAME) publication. All certifiers should be familiar with the CDC death certification concepts; a subset of certifiers (medical examiners and coroners) will also have a working knowledge of the NAME death certification concepts. Inevitably, there will be incremental drift in an individual's practice over time. This work intends to succinctly restate the current rules of death certification as defined by the CDC and, to a lesser degree, as interpreted by NAME. Gaps are also identified. This work is not a comprehensive review of the many nuances or special circumstances of death certification.

When to Autopsy: Idealistic and Realistic Considerations

The decision to perform an autopsy depends on many things, but at the least, it rests with local statutory responsibility and the competent forensic pathologist's perceived needs of the specific case. Although cause and manner of death are at the heart of the mission of the forensic pathologist, there are other obligations that should be considered, such as: questions that could arise later, as well as the impact of an incorrect opinion on the affected family and society. Standards have been developed by the National Association of Medical Examiners (NAME) which state when an autopsy should be performed. The autopsy has value in nearly all cases; however, the indiscriminate use of the autopsy does not supersede the detailed gathering of pertinent investigative history. It cannot be performed in a vacuum. Idealistic virtues of the autopsy, even if based on experiential merit, must still meet the hard realism of budgets and staffing when it comes to categorical case selections for autopsy. Resources must be allocated rationally. The purpose of this discussion/review is to review considerations about whether or not to perform an autopsy, from an idealistic, and from a realistic viewpoint. The intent is not to promulgate dogma or zealous overindulgence in testing which could overburden death investigative systems that already have critical limitations in budget and staffing. The conscientious role of the physician pathologist is emphasized.

Intent in Manner Determination

Manner of death determination is a basic and traditional task for medical examiners. Though it has a history spanning centuries, many facets of manner determination continue to be problematic. Few issues are more vexing than the difficulties in determining intent. A survey of members of the National Association of Medical Examiners was performed to determine current practice and attitudes about the use of intent in manner determination. There were 168 completed responses, representing an approximately 20% response rate. The results reveal significant variation. While the concept of “volition” as distinct from “intent” has been common for over a decade, less than 60% of respondents made the distinction in their practice. There was also wide variation in the degree of certainty practitioners noted they used when determining manner with peaks at between 51-60% and 95-99%. Some of this represents real uncertainty in manner determination and some represents cultural and regional differences in practice. The variation and uncertainty in these determinations has led some to suggest that this role be abandoned. However, the statistical, policy, and cultural need for these determinations dictate that the function will be performed even if abandoned by the medical examiner community. Medical examiners are uniquely positioned and trained to fill this need, and should continue to do so.

Forensic Pathology Fellowship Training Positions and Subsequent Forensic Pathology Work Effort of past Forensic Pathology Fellows

The purpose of this study is to document the number of accredited, funded, and filled forensic pathology fellowship positions in the United States and to document the subsequent work effort of forensic pathology fellowship graduates in terms of whether they go on to practice forensic pathology full time, part time, only as a consultant, or not at all. Also studied is the portion of fellows who become board certified in forensic pathology and/or become members of the National Association of Medical Examiners (NAME). Using surveys of training program directors and the NAME membership, information was obtained for 190 persons who did a forensic pathology fellowship sometime during the years 2000-2005. Information was also obtained from the 35 program directors about the number of accredited, funded, and filled positions in their programs. Among the 35 active programs, 78 positions are approved by the ACGME of which 53 are funded and 42 filled in 2011. Thus, only 68% of approved positions are funded, and 79% of the funded positions are filled. For the 2011 training year, 8 of the 35 programs (23%) have no fellow. Almost equal numbers of men and women trained during the study period. Board certification in forensic pathology was achieved by 67% of 190 trainees and 67% practice forensic pathology full time for an office which conducts official medicolegal death investigations. Unfortunately, 21% end up not practicing forensic pathology at all. 55% of past trainees belong to NAME. A lower portion of women trainees practice forensic pathology full time, and a higher portion of women (26%) do not practice forensic pathology at all, compared with men (15%). For those who obtained board certification in forensic pathology (n=128), 78% were working full time. For those who lacked board certification (n=62), 44% were practicing forensic pathology full time. Forensic pathology fellowship training directors need be aware of these statistics when developing strategies for program development, financial support, and fellow selection. More rigorous evaluation of candidates may be needed to identify those who truly plan to work full time in the field of forensic pathology. Training directors should also take measures to ensure that their programs are not discouraging fellows from continuing their career in forensic pathology. NAME may need to consider ways to attract more graduating trainees into its membership.

Accidental Drug Deaths in Fulton County, Georgia, 2002

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.

Selecting Forensic Pathology as a Career

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. 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. 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. 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.

National Association of Medical Examiners Position Paper on the Medical Examiner Release of Organs and Tissues for Transplantation

The medical examiner community plays a key role in the organ and tissue procurement process for transplantation. Since many, if not most, potential organ or tissue donors fall under medicolegal jurisdiction, the medical examiner bears responsibility to authorize or deny the procurement of organs or tissues on a case-by-case basis. This responsibility engenders a basic dichotomy for the medical examiner's decision-making process. In cases falling under his/her jurisdiction, the medical examiner must balance the medicolegal responsibility centered on the decedent with the societal responsibility to respect the wishes of the decedent and/or next of kin to help living patients. Much has been written on this complex issue in both the forensic pathology and the transplantation literature. Several studies and surveys of medical examiner practices, as well as suggested protocols for handling certain types of cases, are available for reference when concerns arise that procurement may potentially hinder medicolegal death investigation. It is the position of the National Association of Medical Examiners (NAME) that the procurement of organs and/or tissues for transplantation can be accomplished in virtually all cases, without detriment to evidence collection, postmortem examination, determination of cause and manner of death, or the conducting of criminal or civil legal proceedings. The purpose of this position paper is to review the available data, the arguments for and against medical examiner release, and to encourage the release of organs and tissues in all but the rarest of circumstances.

Physicians’ initial forensic impressions of hypothetical cases of pediatric traumatic brain injury

Objective To describe physicians’ initial forensic impressions of hypothetical cases of pediatric traumatic brain injury (TBI) and to compare the responses of pathologists and pediatricians. Method A survey was administered to physicians who attended workshops on pediatric TBI; were members of two national internet list serves; and were members of the Section on Child Abuse and Neglect of the American Academy of Pediatrics ( N = 522) and the National Association of Medical Examiners ( N = 815). The survey included 16 hypothetical case scenarios depicting a pediatric TBI. Participants were asked to categorize their initial forensic impressions of each scenario on a seven-point scale from definitive unintentional to definitive inflicted injury. Results A total of 570 surveys were completed, including 465 of 1337 surveys (35%) distributed through the regular mail. In 8 of 16 hypothetical cases, a majority of respondents (range, 60–98%) and a majority of the more experienced respondents (range, 59–97%) categorized the hypothetical TBI as either unintentional or inflicted. Pathologists were less likely than the pediatric participants to view these scenarios as inflicted TBI. Conclusion Certain features of TBI cases result in a majority of clinicians categorizing them as inflicted or intentional. In the absence of a confession of inflicted injury, witnessed or verifiable events, severe injuries without explanation or injuries that can be linked clearly to a perinatal period, clinicians were unable to agree on the etiology of the injury. Our results will be helpful to other researchers so that consistent, validated research definitions are used to classify pediatric TBI for research purposes.

Infant Deaths Associated With Cough and Cold Medications—Two States, 2005

Cough and cold medications that contain nasal decongestants, antihistamines, cough suppressants, and expectorants commonly are used alone or in combination in attempts to temporarily relieve symptoms of upper respiratory tract infection in children aged <2 years. However, during 2004-2005, an estimated 1,519 children aged <2 years were treated in U.S. emergency departments for adverse events, including overdoses, associated with cough and cold medications. In response to reports of infant deaths after such events, CDC and the National Association of Medical Examiners (NAME) investigated deaths in U.S. infants aged <12 months associated with cough and cold medications. This report describes the results of that investigation, which identified deaths of three infants aged <6 months in 2005, for which cough and cold medications were determined by medical examiners or coroners to be the underlying cause. The dosages at which cough and cold medications can cause illness or death in children aged <2 years are not known. Food and Drug Administration (FDA)-approved dosing recommendations for clinicians prescribing cough and cold medications do not exist for this age group. Because of the risks for toxicity, absence of dosing recommendations, and limited published evidence of effectiveness of these medications in children aged <2 years, parents and other caregivers should not administer cough and cold medications to children in this age group without first consulting health-care provider and should follow the provider's instructions precisely. Clinicians should use caution when prescribing cough and cold medications to children aged <2 years. Moreover, clinicians should always ask caregivers about their use of over-the-counter combination medications to avoid overdose in children from multiple medications that contain the same ingredient.

Organ Donation Breakthrough Collaborative

Organ Donation Breakthrough Collaborative

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.

Death certificate completion: How well are physicians trained and are cardiovascular causes overstated?

To determine the ability of residents in completing death certificates correctly. A total of 4800 residents were asked to complete a survey and cause-of-death statement using a sample case of in-hospital death due to urosepsis, of whom 590 residents (12%) responded. A scoring scale designed based on instructions from the National Association of Medical Examiners and the American College of Pathologists was used to measure responses quantitatively. Overall performance was poor, with only 23% (n = 137) of responses in the optimal scoring range. The average score was influenced significantly by level of residency training, as well as previous experience, prior formal training, and awareness of the guidelines regarding death certificate completion. Optimal scores correlated with level of residency training and prior formal training in death certificate completion, suggesting the benefits of experience and instruction. Forty-five percent (n = 267) of respondents incorrectly identified a cardiovascular event as the primary cause of death. The residents in this study demonstrated suboptimal performance in death certificate completion. Cardiovascular events were often incorrectly identified as the primary cause of death. Formal training can improve performance and should be emphasized in medical schools and residencies.

A Comprehensive Analysis of Forensic Science Training in Forensic Pathology Fellowship Programs

The purpose of this study is to assess the current nature and extent of forensic science training in the nation's 43 Accreditation Council for Graduate Medical Education (ACGME)-accredited forensic pathology fellowship programs. This manuscript describes the results of a survey of training program directors performed as a project for the College of American Pathologists (CAP) Forensic Identity Committee. The results show a considerable diversity in the forensic sciences training in forensic pathology programs, ranging from one to ten weeks, with an average of 4.1 weeks. However, almost one half of programs provide no training in at least one of the surveyed disciplines. Only 58.1% of responding programs meet the ACGME requirements for forensic science training, and a similar percentage (56.0%) currently provides the duration of forensic science training recommended by the National Association of Medical Examiners (NAME). The deficit in the NAME training recommendations, surprisingly, was strictly in the field of toxicology.

Heat-related mortality in selected United States cities, summer 1999.

As part of a public health response to severe heat waves in the midwestern and northeastern United States in the summer of 1999, the authors actively solicited the number of heat-related deaths from 38 medical examiner and coroner jurisdictions comprising 35 metropolitan areas to enumerate heat-related deaths in areas affected by heat waves. They also determined the usefulness of these data for surveillance and rapid investigation of heat-related deaths. A total of 334 heat-related deaths were reported during the study period of July 1 - August 31. Minor changes in data collection and diagnostic criteria in some medical examiner and coroner jurisdictions would allow for greater comparability among jurisdictions. The National Association of Medical Examiners' position paper on heat-related mortality diagnosis provides important guidance to medical examiners and coroners regarding the certification of heat-related deaths and may require some refinement to address certain issues. Among these are certifying manner of death and classifying potential causes of heat-related death not involving hyperthermia or heat stroke, but where heat is a potential contributing factor to death. Medical examiners and coroners are an important resource for heat-related mortality research, and improvements in data collection and reporting could yield tremendous benefits to our understanding of and interventions for heat-related deaths.

Report on the 2003 revision of the U.S. Standard Certificate of Death.

The National Center for Health Statistics (NCHS) is responsible for publishing Standard Certificates of Birth and Death for the United States of America. The standard certificates are revised roughly every 10 years. The revision process is designed to ensure that the standard certificates meet, as nearly as possible, the use for which they are intended at all levels: individual, local, state, and federal. The authors report on the most recent revision of the U.S. Standard Certificate of Death, recording the process and the role of the National Association of Medical Examiners in the process. Changes recommended during revision include requesting known aliases of a decedent and rearrangement of the certificate to provide more room for those items requesting dates and for describing how the injury occurred. New items have been added asking for information regarding traffic fatalities, the role of tobacco use in causing death, and whether female decedents were pregnant. Once approved by the Department of Health and Human Services, the new standard certificate will be made available to the states. Each state will have 2 years to adapt the U.S. Standard Certificate of Death to its use and to implement new state death certificates on January 1, 2003.

Mind your manners. Part III: Individual scenario results and discussion of the National Association of Medical Examiners Manner of Death Questionnaire, 1995.

In 1995, a questionnaire was distributed to the > 700 physician medical examiner/coroners (ME/Cs) who are members of the National Association of Medical Examiners (NAME, St. Louis, MO, U.S.A.). The questionnaire consisted of 23 death scenarios for which individual responders were asked to assign a manner of death (homicide, suicide, accident, natural, or undetermined); 198 questionnaires were completed and analyzed. The distribution of manner of death responses was tabulated. In addition, a nosologist from the National Center for Health Statistics was provided with a cause-of-death statement based on each scenario and was asked to assign an International Classification of Diseases (ICD) code for the underlying cause of death, from which a manner of death was inferred from the ICD code's literal text description. Overall, agreement on a given manner of death in a single scenario was > 90% in only 4 of 23 scenarios and > 70% in only 12 of 23 scenarios. However, in 21 scenarios, the most common response comprised a majority. The manner of death inferred from the ICD code that was assigned by the National Center for Health Statistics (NCHS) matched the most common response of participants in 18 of the 23 scenarios. The questionnaire results show that there is substantial disagreement among experienced MEs concerning the manner of death classification that is preferred for selected types of death. Encouraging, however, is the fact that the manner of death coded for statistical purposes generally agreed with the most common classification of manner made by ME/Cs. Highlights from the discussion of each scenario that occurred during the NAME interim meeting (Nashville, Tennessee, February 1996) are also included. Other portions of the program including history of manner of death concepts and results of questions regarding responder training and characteristics are published separately in this issue of the Journal. Information derived from the questionnaire should be useful to those planning strategies to improve the consistency of manner of death classifications by ME/Cs.

National Association of Medical Examiner's Pediatric Toxicology (PedTox) Registry

In 1985, the National Association of Medical Examiners (St. Louis, MO) established a Pediatric Toxicology (PedTox) Registry to collect case reports of drugs and substances detected in children. For many drugs and substances detected in children, to date, the medical and toxicology literature contain little useful information regarding toxic and lethal concentrations, and the PedTox Registry was established to provide additional information to those who must interpret observed concentrations of drugs and substances in children. This article includes a description of the development of the PedTox Registry, its management, and a brief summary of data that have been published, including information for acetaminophen, benzene, carboxyhemoglobin, codeine, desipramine, dextromethorphan, ethanol, phenobarbital, phenylpropanolamine, and pseudoephedrine.

History of the National Association of Medical Examiners and Its Meetings, 1966–93

Although the National Association of Medical Examiners (NAME) is now more than 25 years of age, no comprehensive history of its organization, meetings, and milestones has yet been published. lnfonnation must be gathered from many disparate sources, including records in the St. Louis office, program brochures from meetings, the personal memories of members, and the recent audiotapes of some conference presentations. To provide an introduction to and a historical perspective on NAME for newcomers to the field of forensic pathology and death investigation. and to furnish documentation that may be useful as a reference or for future NAME planning. I have attempted to summarize the first 25 years of NAME's existence. Since J have only been a NAME member for slightly more than a decade and therefore must rely heavily on administrative documents, program brochures, and information gleancq during the afterhours get-togethers with other members of our closely knit group, some important details may have been omitted or presented incorrectly in my account; if so, I apologize to those affected. I also concede that some of the editorial comments at the conclusion of this article may prove to be a source of contention for some readers; nevertheless. these comments reflect things as I perceive them. So, in the beginning ...

National Association of Medical Examiners Pediatric Toxicology (PedTox) Registry Report 3

Data are presented from the National Association of Medical Examiners' (St. Louis, MO, U.S.A.) Pediatric Toxicology (PedTox) Registry. A total of 839 case reports have been submitted to the registry. Reported here are the concentrations of several drugs and potentially toxic substances observed in children who have died of various causes, often non-drug-related. Except for carbon monoxide, for each of the substances addressed in this report, there is insufficient information in the literature to distinguish "lethal" from "non- or sublethal" concentrations in children, and the data are presented only to provide a working frame of reference. For 30 infants whose deaths were attributed to causes other than phenobarbital, the median blood phenobarbital concentration was 7.8 mg/L, with a range of 0.1-22.4 mg/L. For eight infants whose deaths were not attributed to ethanol, the mean blood ethanol concentration was 0.029 gm/dl and ranged from 0.011 gm/dl to 0.050 gm/dl. Blood dextromethorphan concentrations in seven infants showed a mean of 0.38 mg/L and ranged from 0.10 mg/L to 0.95 mg/L. In 15 infants, blood pseudoephedrine concentrations ranged between 0.07 mg/L and 13.0 mg/L, with a mean concentration of 3.55 mg/L. Blood carboxyhemoglobin saturations for 38 children aged < or = 5 years, who died in fires and were dead on the scene and not resuscitated, ranged between 29% and 94%, with a mean saturation of 64%. Blood benzene concentrations in eight children aged < or = 6 years who died in fires and were dead on the scene showed a mean concentration of 2.3 mg/L and a range of 0.2-4.9 mg/L. For 33 children aged < or = 5 years whose deaths were attributed to nondrug causes, the mean blood acetaminophen concentration was 9.9 mg/L, and the range was 1.0-34.5 mg/L. These data are not well controlled in terms of testing methodology or cause of death determinations and should not be used as the sole source of information when assessing whether or not a death is caused by one of these substances. Further data and controlled studies are needed to work toward establishing lethal concentrations of certain drugs and toxic substances in children, and the reporting of cases to the PedTox Registry is encouraged.