Office Of Chief Medical Examiner Research Articles

Use of “Therapeutic Complication” as a Manner of Death

Analyses of deaths due to therapeutic complications (TCs) provide important quality of care information for medical providers. In New York City, 463 deaths were investigated by the Office of Chief Medical Examiner and certified with TC as the manner of death in 2003. The TC manner of death is used for fatalities due to predictable complications of appropriate medical therapy. All death certificates and select autopsy, hospital, and investigation reports were reviewed. Data concerning cause of death, contributing conditions, age, race, and sex were extracted. The types of complications and the causes of death were classified into various types of surgical and nonsurgical categories of complications. These included: postoperative infections, pulmonary emboli, and technical and medication complications. The use of TC as a manner of death has benefits and limitations. Without the TC option, one is forced to certify certain deaths (e.g., penicillin anaphylaxis) either as natural or accident. The TC option allows easy identification and tracking of medical complications for public health purposes and also allows more consistent reporting of natural and medical-accidental deaths. In general, complications that occur during emergency surgeries/procedures for natural disease, tend to be certified with a natural manner. The "but for" test may be used to distinguish natural from TC deaths. There are criteria for distinguishing TC from accidents and homicides. TCs that occur during treatment of a potentially life-threatening injury, are superseded by the manner dictated by the circumstances of the initiating injury. The certification of TC usually does not address errors of omission, clinical judgement/management, or missed diagnoses.

9/11 and the new york city office of chief medical examiner.

On September 11, 2001 two hijacked airplanes struck the Twin Towers at the World Trade Center in New York City. All of the remains (19,915) were examined by the Office of Chief Medical Examiner (OCME) of New York City. The major goals of the OCME were to accurately identify the decedents and to promptly issue death certificates. As of September 2005, there were 1594 identifications of a total of 2749 people reported missing. Of these, 976 were identified by a single means, which included DNA analysis in 852 of the victims. Use of legal statues can assist in the timely issuance of death certificates in mass fatalities, which benefit surviving family members. DNA analysis markedly improves the ability to identify remains and has become the standard method for identification in these types of disasters. Certain postmortem tissue samples are better suited for DNA analysis and yield better results than others.

Identification of N, N-dimethylamphetamine formed by methylation of methamphetamine in formalin-fixed liver tissue by multistage mass spectrometry

Methamphetamine is methylated in the presence of unbuffered formalin solutions within hours at room temperature. The product, N, N-dimethylamphetamine, is also found in human liver exposed to methamphetamine followed by incubation with formalin. In the present study, a direct mass spectrometric method was developed to identify N, N-dimethylamphetamine in human liver before and after treatment with formalin. Human liver samples were obtained from four deaths that were investigated by the West Virginia Office of Chief Medical Examiner. Full toxicological analysis was conducted on samples from the decedents and methamphetamine was among the positive findings in each case. The method used to expose liver tissue to formaldehyde involved treating a small piece of liver from each case with formalin solution (20% v/v) for 24 h at room temperature. The formalin treated tissues were homogenized and the resulting suspension was sonicated for 5 min, and then centrifuged. Supernatant aliquots were directly analyzed by electrospray ionization (ESI) mass spectrometry without chromatographic isolation. Positive ion multistage mass spectra recorded in MS, MS/MS and MS/MS/MS (MS 3) modes were used to confirm the presence of N, N-dimethylamphetamine and methamphetamine in the mixture. Liver tissue not treated with formalin did not contain a detectable level of N, N-dimethylamphetamine. Decreases in methamphetamine concentrations in liver tissue resulting from treatment with formalin were measured using deuterium-labeled methamphetamine as internal standard. The method can be completed in less than 2 h on thawed tissue. The results suggest that the process of fixing tissues with formalin may lead to false negative findings for methamphetamine.

Fatal Pulmonary Thromboembolism and Hereditary Thrombophilias

Pulmonary thromboembolism (PE) is found commonly in forensic pathology practice, as it typically causes sudden death. It is attributed to a wide variety of predominantly acquired etiologies. Although likely etiologically multifactorial, some common proximate causes include: surgery, pregnancy, injury, inactivity of any cause, cancer, obesity, or serum hyperviscosity. On occasion, no apparent predisposing condition is identified. In these instances, occult hereditary thrombophilias may play a causal role. Deaths referred to the Office of Chief Medical Examiner (OCME) of New York City between December, 2000 and September, 2003 and due to PE were retrospectively reviewed. Molecular analysis (FRET) was performed on selected cases for three common hereditary thrombophilias: mutations in factor V Leiden (FVL), prothrombin G20210A (PT), and methylenetetrahydrofolate reductase (MTHFR). During the study period, 124 of 15,280 deaths were primarily attributable to PE. Of those, 34 were selected for molecular analysis. One or more mutations were detected in 35% of those, five of which were clearly causally related to death. Given the potential benefits to surviving family members, our data indicate that postmortem molecular testing for the common hereditary thrombophilias is warranted in at least selected cases.

PEDIATRIC HEADACHE

Spontaneous cerebellar hemorrhages are a rare but often fatal occurrence in children. Although there are several predisposing factors such as blood dyscrasias or astrocytomas, the most common cause of cerebellar hemorrhage in an otherwise healthy child is the rupture of a vascular malformation. We reviewed the files of the Office of Chief Medical Examiner of the City of New York and found four such instances over a period of less than two years. We present these here and outline the approach the forensic pathologist should take in evaluating such deaths. Comment: Possibly more common than we thought? SJT

Mortality in Cerebral Palsy (CP): The Importance of the Cause of CP on the Manner of Death

Cerebral palsy (CP) is a nonprogressive motor deficit present or sustained in the perinatal period. We reviewed the files of the Office of Chief Medical Examiner of the City of New York for the 1997-2001 interval seeking those with any mention of cerebral palsy. There were 26 such cases, including 18 natural deaths, three accidents, two homicides, two therapeutic complications, and one death classified as undetermined. Proper reporting and careful investigation of these deaths is required for accurate certification of cause and manner of death, as well as for adequate tracking of these deaths for public health purposes.

Spontaneous Cerebellar Hemorrhage in Children

Spontaneous cerebellar hemorrhages are a rare but often fatal occurrence in children. Although there are several predisposing factors such as blood dyscrasias or astrocytomas, the most common cause of cerebellar hemorrhage in an otherwise healthy child is the rupture of a vascular malformation. We reviewed the files of the Office of Chief Medical Examiner of the City of New York and found four such instances over a period of less than two years. We present these here and outline the approach the forensic pathologist should take in evaluating such deaths.

Schizophrenia as a Cause of Death

Schizophrenia is a chronic disorder that is associated with increased mortality. Although traumatic deaths account for most of this increase, there is also an increased rate of natural deaths in this population. Altered autonomic physiology in this group might contribute to death. To determine if there are schizophrenics in whom, after a complete autopsy, no recognizable cause of death other than schizophrenia is established, the records of the Office of Chief Medical Examiner of the City of New York were reviewed for deaths associated with schizophrenia and a natural manner of death. Six such decedents were identified, and their histories and autopsy results are described. We believe that schizophrenia per se is a potentially lethal disorder. Autonomic irregularities and their interactions with psychotropic drugs deserve further attention.

#44 Changing racial/ethnic disparities in homicide mortality in nyc 1990–98

PURPOSE: Homicide mortality rates have historically been higher among African-Americans (AAs) than whites in the US. There has been a significant decrease in homicide mortality in New York City (NYC) during the past decade. We were interested in determining how disparities in homicide mortality between racial/ethnic groups have changed during that time and if drugs played a role in these changes. METHODS: All homicides in the NYC Office of Chief Medical Examiner records for 1990–1998 were identified. We calculated annual age and race standardized rates of homicide with positive toxicology. We calculated proportions of white, AA, and Hispanic decedents with positive cocaine, opiates, cannabis, and alcohol toxicology for each year in the period. RESULTS: Between 1990 and 1998, overall homicide rate decreased from 28.6 to 6.92 per 100,000 (75.8%). In 1990, the homicide rates among AAs and Hispanics were 9.5 and 8.2 times greater than among whites respectively. In 1998, homicides among AAs and Hispanics were 7.9 and 3.8 times greater than among whites. Proportion of homicide decedents with positive toxicology was stable and similar for all three groups between 1990-98 (range: 74.6% to 89.2%). The proportion of homicide decedents with positive cocaine toxicology declined, the proportion of decedents with positive cannabis toxicology increased, and the proportion of opiate and alcohol positive decedents was stable during the period. Changes in proportions of drug-positive homicide decedents were similar for all drugs for whites, AAs, and Hispanics between 1990–1998. DISCUSSION: Although overall homicide rates in NYC declined between 1990–98, there remained substantial disparities in homicide rates between whites, AAs, and Hispanics at the end of the decade. Proportions of homicide deaths with positive toxicology changed similarly in all three racial/ethnic groups. Factors other than drug use likely account for the persisting racial/ethnic disparities in homicide rates in NYC.

Fatal Descent from Height in New York City

All deaths due to descent from height that underwent autopsy at the Manhattan Office of Chief Medical Examiner of New York City over a two year period (1997-1999) were reviewed. The scene and autopsy findings, psychiatric history, and toxicology results were examined. There were 120 deaths: 77 suicides, 36 accidents, 5 undetermined, and 2 homicides. Psychiatric illness was reported in 86% of suicides. The toxicological detection of psychiatric medications supports the high percentage of psychiatric disease in the suicide group. In the accidental group, the detection of ethanol and illicit drugs was higher (36%) than expected from the case investigation and similar to the suicide group (29%). Accidental falls by women made up fewer than 3% of all manners. Due to the variation in the extent of injuries, it is unwise to attempt to conclude how high a person descended based on the autopsy findings. Descents into water commonly have minimal findings on external examination with marked internal injuries. The methods of investigation and criteria for death certification using the study results are discussed.

Ketamine in Non-Hospital and Hospital Deaths in New York City

We reviewed all ketamine-positive deaths (87) examined at the New York City Office of Chief Medical Examiner over a two-year period (1997 to 1999). There were 15 non-hospital deaths with 12 due to acute multidrug intoxications, one due to sarcoidosis, and two due to physical injury (blunt and thermal). In no instance was a fatal intoxication caused exclusively by ketamine. Opiates (10/15), followed by amphetamines (7/15) and cocaine (6/15), were the most frequent co-intoxicants. Ethanol was found in only one death. The race of all decedents was white and the majority were men (11/15) between the ages of 18 and 30 years. The remaining 72 instances of positive ketamine findings were hospital deaths following surgical procedures or burns.

HIV Seroprevalence Rates Among Homicide Victims in New York City: 1991–1993

This study assessed HIV seroprevalence in homicide victims killed in New York City in 1991-1993, using data from the Office of Chief Medical Examiner. Among 5852 homicide victims there were 344 (5.9%) victims who were HIV positive. Females were just as likely as males to be HIV positive. For females, the highest rates were in the 25-34 year (11.7%) and 35-44 year (12.6%) age categories. For males the highest rates were in the 35-44 year (13.7%) and 45-54 year (11.5%) age categories. Other than there being no HIV positive Asian victims, there were no differences in HIV rates among racial/ethnic groups. The highest rates of HIV infection for homicide victims were among those using both opiates and cocaine (males: 23.0%; females: 27.3%). Women, not men, using cocaine alone had a high HIV positive rate (18.4%). Victims not using these drugs had rates of HIV around 2%. The authors believe that the high risk of HIV among homicide victims, may be due to the use of cocaine and associated risky use of needles and risky sex practices.

A Bloodstain Pattern Interpretation in a Homicide Case Involving an Apparent “Stomping”

A New York City homicide case was investigated at the request of the District Attorney's office. The deceased had been violently beaten about the face, neck, and chest area. The bludgeoning left the victim unrecognizable, and produced blood-spatter patterns at the scene that attained heights over nine feet. The suspect claimed that he reacted in self-defense to the victim's attack with a table leg at which point he "knocked him down" and possibly "kicked him a few times." Our investigation was intended to determine whether the bloodspatter patterns observed at the crime scene were consistent with the statements made by the defendant. Conclusions were drawn from an analysis of the crime scene, autopsy photos and report, physical evidence submitted to the laboratory, and reconstruction experimentation performed at the Office of Chief Medical Examiner (OCME). The spatter patterns observed at the scene were found to be consistent with those that would be produced from a "stomping" incident.

Cocaine and fetal death

Toxicologic screening for cocaine and its metabolites was performed on 103 cases of fetal death autopsied in the Office of Chief Medical Examiner, City of New York. In 64 cases cocaine or its metabolites were found in the blood or in the brain. Some malformations were also found. The study indicates that maternal use of cocaine may lead to abruptio placentae, abortion and fetal death. The importance of toxicologic examination in these deaths is emphasized.

Confirmed identification of biotransformed drugs of abuse in urine.

A procedure that has been developed during the past 6 years at the Office of Chief Medical Examiner in New York City for rapid routine identification of drugs of abuse in urine is described. The urine is extracted at acidic, strongly basic, and weakly basic pH; the last, pH 8.5, fraction is hydrolyzed to increase extractable morphine and codeine. The residues are subjected to thin-layer chromatography and suspected spots scraped from the plates and confirmed by microcrystal examination or spectrofluorometry. Amphetamines, quinine, methadone, meperidine, propoxyphene, pentazocine, cocaine, and phenothiazine are present in the strongly basic extract. The acidic drugs, in particular barbiturates and glutethimide, are confirmed by gas–liquid chromatography. This procedure has proved effective for the routine analysis of more than 300 urine specimens daily for court purposes as well as for a variety of drug abuse identification, treatment, and follow-up programs. A rapid sensitive microchromatographic method for detection of marijuana components from teeth and fingers is also described.

Follow-up study of fatal penicillin reactions; special report.

During the years 1952 and 1953, the Office of Chief Medical Examiner of the City of New York investigated eight fatal reactions after penicillin injection, and I published a report in theNew York State Journal of Medicineof May 15, 1954, entitled Eight Fatal Anaphylactic Reactions to Penicillin.1This article was immediately widely reported in the lay press in many lands and languages. In the Sept. 4, 1954, issue ofThe Journalthere appeared a full abstract of the article. In the November, 1954, issue ofCoronetmagazine, a lay science writer abstracted the original article without our knowledge and called it Penicillin Turns Killer. From the time of the publication of the original article, a large amount of mail was received both from the medical profession and from the allied professions and laity. All the above is mentioned because by the time the stir this article created