Principles of Forensic Pathology : From Investigation to Certification

Principles of Forensic Pathology: From Investigation to Certification offers a conceptual framework and foundational approach to a forensic practice grounded by evidence-based and mechanistic thinking. This book uses a systematic approach to address, explain, and guide the reader through diverse topics relevant to forensic pathologists and medicolegal death investigators. Nineteen chapters provide a comprehensive overview of the field of forensic pathology and discusses central topics such as scene investigation, the pathophysiology of death, death certification, the forensic autopsy, forensic imaging, pediatric forensic pathology, the importance of context, and approaches to frequently encountered medicolegal death circumstances, with mental checklists and suggestions for a consistent and considered approach. Written by forensic professionals, this book is a practical, yet comprehensive compendium for practicing forensic pathologists, coroners, medicolegal death investigators, forensic pathology fellows, pathology residents, medical students interested in forensic pathology, lawyers, and law enforcement professionals. Presents a primary text that is ideal for daily forensic practice Discusses how to properly investigate and certify death in a consistent and defensible way Emphasizes best practices in the field, providing an approach that is in line with today's forensic pathologist Front Cover PRINCIPLES OF FORENSIC PATHOLOGY PRINCIPLES OF FORENSIC PATHOLOGY Copyright Dedication Contents List of contributors In memoriam References Biography SUSAN F. ELY Biography JAMES R. GILL Foreword Preface Acknowledgments ABOUT THE ARTIST (COVER ART AND ALL MEDICAL ILLUSTRATIONS) 1 - Forensic pathology: overview Introduction: who we are and our unique role as physicians Historical perspective Coroner versus medical examiner systems in the United States and abroad What constitutes “medical examiner/coroner jurisdiction”? The forensic autopsy (see also Chapter 5) Death certification (see also Chapter 3) Planning for a career in forensic pathology: advice to future trainees References 2 - Thinking forensically: planning, anticipating, observing, documenting, inquiring, synthesizing, opining, and co ... The importance of context The role of inference: releasing the grip on exclusively anatomic findings Objectivity, neutrality, and observational acumen: being autoptic Anticipating, planning, observing, documenting, inquiring, synthesizing, opining, and communicating, in that order Preautopsy analysis and planning Anticipating questions and future issues Postautopsy analysis and planning Observing and documenting Documentation The value of pertinent negatives Considering disease and injury lethality Injury pattern recognition Consider the mechanism of death before leaving the autopsy room Inquiring Interpreting and synthesizing Opining Possibilities Probabilities Reasonable degree of medical/scientific certainty∗∗ Certainty beyond a possible doubt (100% certainty) Making “pending” death certification decisions Communicating References 3 - The pathophysiology of death and death certification The pathophysiology of death Death certification Cause of death “Pending” death certificates Common death certificate mistakes Manners of death Natural deaths Therapeutic complications Accidents Suicides Homicides Undetermined cause and/or manner War injury Other death certificate fields and miscellaneous issues Injury information The importance of “how injury occurred”: Do's and Don'ts Time of death/found/pronounced and miscellaneous information Assigning gender on death certificates Injury at work YES NO Death certificates in disasters/mass fatality incidents (see also Chapter 4)128 Key death certification tips References 4 - The scene investigation, postmortem changes, and time of death The written narrative General tips Anaphylaxis and food Asthma/emphysema Bathtub deaths (see also Chapters 6 and 11) Cancer Carbon monoxide (nonfire) (see also Chapter 14) Choking on food (see also Chapter 11) Communicable disease (e.g., tuberculosis, meningitis, CJD, etc.; see chapter 17) Tuberculosis and meningitis AIDS/HIV Creutzfeldt–Jakob disease Novel coronavirus (COVID-19) Delayed hospital deaths following recent or remote injury (see also Chapter 15) Descent (fall versus jump) from height Diabetes mellitus Drowning (see also Chapter 13) Drugs and ethanol/substance misuse deaths (see also Chapter 14) Communication with families (see also Chapter 16) Family preferences for and objections to autopsy Final exit suicides (see also Chapter 11) Fire (see also Chapter 12) Gastric bypass surgery (see also Chapter 8) Gunshot wounds (also see Chapter 9) Head injury (also see Chapter 10) Deaths following heart surgery Hip fractures Hospital bloods (see also Chapter 14) Hyperthermia/hypothermia (see also Chapter 13) Infants/newborns (see also Chapter 6) Injuries in general Kidney disease Liver disease Medications at scene Motor vehicle collisions (see also Chapter 10) Multiple medical diseases/potential causes of death “No scene”/public view/direct to ME/C deaths Obesity Organ donation Occupational safety and health administration–OSHA (see also Chapter 3) Pregnancy (see also Chapter 3) Seizures (see also Chapter 7) Sharp injury (see also Chapter 10) Stillbirths (versus live births) (see also Chapter 6) Suicides Sudden death Surgeries and therapeutic complications121,122 (see also Chapter 8) Time of death/found/pronounced Postmortem changes and establishing the basis for postmortem interval estimates Environmental variables Bodily variables Time of death versus time of pronouncement: reports and testimony The trauma scene Crime scenes and deaths in public view Crime scenes Deaths in public view Field challenges in the recognition and identification of human skeletal remains Attempts at postmortem concealment of bodies in homicides (dismemberment, incineration, and burial) Mass fatality incidents (MFI) Avoiding the top 10 investigative oversights References 5 - The forensic autopsy The big picture The forensic autopsy: general tips Photography Radiography Radiologic tasks and tips Suggestions: Evidence Clothing The sexual assault kit Suspected weapons Ballistics evidence The standard external autopsy examination The standard internal autopsy examination Cardiovascular pathology Neuropathology Forensic anthropology Toxicological sampling Histology Microbiology Approach to the trauma autopsy Special techniques and examinations Eye enucleation Intracardiac air embolism The layered anterior neck examination The posterior neck examination83–85 Concerns for sexual assault Postmortem sperm harvesting Pulmonary thromboembolus and posterior lower extremity dissection Dissections of surgical and injection sites Pedestrian fatalities: special procedures Dissection of the facial soft tissues and skeleton Full body flay Autopsy of the pregnant or recently pregnant woman The negative autopsy: the importance of what we exclude Organ and tissue donation Dissections and the funeral home Religious objections to autopsy The forensic team: investigators, technicians, clerical staff Quality assurance Safety in the autopsy environment Sharp injury risk Radiation risk Cardioverter-defibrillator risk References 6 - Approach to forensic perinatal and pediatric pathology Initial investigation Primary scene Reenactment Medical history Radiology Photography The pediatric autopsy External examination Postmortem changes and artifacts Evidence of therapeutic intervention Clothing Injuries Internal examination General Body cavities Head and spinal cord Neck Cardiovascular system Respiratory system Digestive system Genitourinary system Hematolymphoid system Endocrine system Musculoskeletal system Histology Neuropathology Toxicology Metabolic studies Microbiologic studies Molecular genetics Forensic odontology Forensic biology Forensic anthropology Pediatric trauma Blunt impact injuries Fatal child abuse syndrome (aka, battered child syndrome) and abusive head trauma Fatal child abuse syndrome Abusive head injury Patterns of inflicted injury: infants versus toddlers/preschoolers Asphyxia Bathtub drownings Thermal injuries Neglect Consultations Child fatality review boards Mandatory reporting Home births: stillbirth versus live birth Approach to the live born versus stillborn infant/fetus and possible neonaticide Was the baby stillborn or live born? Autopsy: determination of gestational age, live born versus stillborn, and cause of demise or death Investigative issues and checklist Potential etiologically specific causes of neonatal death or fetal demise What is SUID, SIDS, SUDC, and SUDP? Death certification History of SIDS and sudden unexplained death in infancy Conclusion References 7 - Approach to natural deaths (adult) The sudden and unexpected death Sudden Unexpected Cardiac Coronary arteries Myocardium Cardiac valves The conduction system Specific forensic issues in sudden cardiac death Sudden death in young athletes103–109 Sudden cardiovascular death in hostile environments Pulmonary thromboembolism Seizure-related deaths and epilepsy Seizure investigation Posttraumatic epilepsy Medications Autopsy and postmortem work-up Death certification Anaphylaxis Alcohol use disorder (formerly known as chronic alcoholism) and chronic substance use disorder Alcohol use disorder Chronic substance use Pancreatitis Gastrointestinal hemorrhage (GIH) Bronchial asthma Dementia and old age Diabetes mellitus Obesity as a cause of death Bronchopneumonia Sudden death and chronic renal disease Sudden death from endocrine disorders Sudden death and psychiatric disease Sickle cell disease and trait Human immunodeficiency virus References 8 - Approach to medical intervention‐related deaths Therapeutic complications Categories and examples of therapeutic complications Operative Nonoperative Procedural Deaths related to cosmetic, weight loss, and dental procedures Liposuction and fat transfer Bariatric surgery The dental office Accidents and homicides in medical settings Medical accidents Medical homicides References 9 - Approach to firearms deaths Deaths due to trauma Firearm injury Graze and tangential gunshot wounds Retractor artifact Bullet “bookkeeping” Range of fire Penetrating gunshot wounds Kinetic energy Yaw Bullet construction and configuration Tissue factors (density, elasticity, and strength) Intermediary objects/targets Mechanisms of death in firearms fatalities Manners of death in firearms fatalities: homicides, suicides, and accidents Gunshot residue testing (GSR) Rifles (rifled long guns) Shotguns Ballistics Conclusion References 10 - Approach to blunt, sharp, and transportation deaths Blunt injury Craniocervical trauma Skull fractures Epidural, subdural, subarachnoid, and intracerebral hemorrhages Cerebral cortical contusions Traumatic axonal injury Secondary processes Neck injury Approach to unwitnessed fatal blunt head and torso trauma Sharp injury Chop injury Sharp injury tips Transportation injury References 11 - Approach to asphyxial deaths Asphyxia Asphyxia: accidental and suicidal Approach to potential choking deaths Approach to lack of environmental oxygen Approach to final exit (and similar) deaths Approach to hangings Characteristics of the ligature Degree of suspension Duration of suspension before body discovery Placement of the ligature in the neck's vertical dimension Location of the point of suspension Approach to potential positional asphyxia deaths Approach to asphyxia: homicides Facial/Conjunctival petechiae and asphyxia Loss of consciousness Time to death Carotid sinus and vagal inhibition Manner of death References 12 - Approach to burns, blast, and radiation injury Thermal and inhalational injury Fire Scald and heat burns Chemical/irritant burns Blast/radiation injury Blast injury Radiation injury Animal attacks, domestic and in the wild References 13 - Approach to environmental deaths Drowning The approach to bodies in public waterways (pools/oceans/rivers/lakes) Certification of waterway deaths Scuba (air embolism) Near-drownings Electricity Electrical burns Electrocutions The science of electricity How does electricity kill? Typical electrocution scenario and investigation Lightning Electromechanical control devices Environmental exposure: hyperthermia Environmental exposure: hypothermia References 14 - Approach to toxicological deaths History and scene investigation Autopsy examination Toxicology testing Autopsy samples Death certification Opioids Stimulants Examples of drug intoxications Opioids, benzodiazepines, and other depressants The combination of opioids and stimulants Novel (new) psychoactive substances Opioids and natural and synthetic cannabinoids Methadone Three scenarios: The effect of drug metabolism on toxicology results Postmortem drug redistribution and breakdown Natural disease in the presence of intoxicants Toxicology testing and trauma deaths Toxicology testing following hospitalization Interpreting toxicology test results in the decomposed body Drug packers (“Mules”) Suicide versus accident The apparent drug intoxication death with negative toxicology and no anatomic cause Legal implications of mixed drug intoxications and other special toxicologic considerations Miscellaneous toxicological issues Nitrites and poppers Cyanide Arsenic Ethylene glycol Anticholinesterases Acetaminophen Sodium azide Toxicological considerations in pediatric deaths References 15 - Special topics: in-custody deaths, physical altercations, neglect (adult), approach to unexpected hemorrhage, ... Deaths in detention centers/correctional facilities/police custody Deaths in the setting of police restraint Hyperactive delirium (so-called “excited delirium”) Suicidal behavior in law enforcement encounters The investigation Police investigations and the medical examiner/coroner Physical struggles: contact, altercations, and the death certificate Abuse and/or neglect in the debilitated adult or teen The establishment of dependence Autopsy/physical evidence Police/district attorney/forensic investigator evidence Approach to hemorrhage of unclear origin (unexpected hemorrhage found at autopsy) Head Neck Thorax Peritoneal cavity Gastrointestinal Retroperitoneal and rectus sheath (soft tissue) Delayed deaths due to remote injury: issues and concepts Approach to dismembered remains and other forms of postmortem concealment The forensic anthropologist Dismemberment Postmortem incineration Postmortem burial References 16 - Communication Overview Verbal: one-on-one communication On speaking with families and to juries Testifying in legal forums Inquiries from attorneys Testimony at depositions, grand juries, or trials Depositions Grand jury Trial Steps in the preparation for testimony The courtroom Standard qualification questions (with some examples of responses): Typical direct examination questions: Cross-examination questions: Potentially challenging or otherwise tricky questions Time of death estimates and postmortem changes: caveats and approach Objections raised while on the stand Testimony tips Being called to testify in a former jurisdiction Miscellaneous Top 10 testimony tips High-profile deaths, media inquiries, and press offices Silence or nonresponsiveness Handling individual inquiries from the media Press releases Press conferences Interviews Relationship with the media Release of information Consideration of families and the media Tone Mistakes Public speaking: case presentations, lectures, and teaching Case presentations Formal lectures Teaching Written communication Tips on crafting a forensic autopsy report References 17 - The forensic pathologist's public health role Introduction Background Passive surveillance Vehicular fatalities Occupational fatalities Violent deaths Active surveillance Adverse medication/medical device events Adverse vaccination events Unsafe consumer product events Death review teams Identification of missing and unidentified persons Detection and characterization of infectious disease Conclusion References 18 - Developments in postmortem imaging Introduction CT basics Hounsfield units Artifacts Approach to PMCT interpretation Head and neck Chest Abdomen and pelvis Bones Support devices CT reporting Example CT reporting template Radiologic identification Postmortem CT angiography Image-guided procedures Postmortem and decomposition changes on imaging Mummification, skeletonization, predation, and charred remains Mummification and skeletonization Predation Charred remains Natural disease Brain Heart Pulmonary Liver SARS-CoV-2 relating findings Blunt force trauma Blunt head trauma Blunt neck trauma Blunt chest trauma Blunt abdominal trauma Blunt extremity and pelvic trauma Penetrating injury Drug intoxication Pediatric imaging Appendicular fractures Foreign bodies Pro tips/pearls Forensic pathology postmortem imaging training curriculum: the New Mexico experience Future directions References 19 - Recent and ongoing technological advancements in forensic pathology practice The role of molecular genetics in sudden and unexpected deaths Cardiac-focused Aortopathies Thrombophilias Epilepsy-focused Hemoglobinopathies Rapid DNA Digital fingerprinting 3D printing and anthropology Facial reconstruction and recognition References I - Appendices A - Formats of autopsy report final diagnoses General formats for final diagnoses lists Gunshot wounds Gunshot wounds with subsequent therapy Blunt trauma Reference B - Format of the autopsy report Formats for the “Injury” section Gunshot wounds Penetrating/perforating gunshot wound of2 ... Multiple gunshot wounds Shotgun wounds Blunt force trauma Head and neck Trunk/Torso Extremities Sharp force trauma Stab wounds Wound appearance Incised wounds . Asphyxia . Thermal C - Autopsy report templates Autopsy templates by type General/generic dictation template External examination Postmortem changes Tattoos Therapeutic/diagnostic procedures Clothing Injuries, external and internal Internal examination Microscopic tissue examination Toxicology Neuropathology/cardiac pathology Microbiology Molecular genetics Forensic biology Forensic imaging Evidence: (examples) Pediatric dictation Generic pediatric autopsy dictation template External examination Placenta and umbilical cord Postmortem changes Therapeutic interventions Injuries, external and internal Internal examination Microscopic tissue examination Toxicology Neuropathology/cardiac pathology Microbiology Molecular genetics Metabolic studies Forensic biology Forensic imaging Evidence Gunshot/shotgun wound templates Injuries, external and internal Entrance wound Notes Track with associated injury/sequelae Exit wound (or site of lodgment) Course and direction Notes Bullet (only for penetrating wounds or for bullet fragments left behind in perforating wounds) Clothing Shotgun wounds Injuries, external and internal Entrance wound Modifications Track Exit wound/site of lodgment Course and direction Notes Clothing Blunt force trauma template Injuries, external and internal Notes Sharp force trauma templates Injuries, external and internal Notes Incised wounds Notes Injuries, external and internal Notes Hanging template Injuries, external and internal Thermal burn injury template Injuries, external and internal D - Library for forensic pathology fellows References E - Hirschisms and Adelsonisms . Hirschisms . Adelsonisms References Index A B C D E F G H I K L M N O P Q R S T U V W Y Back Cover