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Limitless Horizons and Exciting Promises
Mary Ann Sens, MD. PhD Altru Health Systems Healthcare Horizons
October 18, 2011
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Limited View of Forensic Pathology
Forensic Pathology
Legal Implications
Law Enforcement
Court Systems
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Forensic Pathology
Classic Disease
Quality Review
Clinical
Students
Police, EMS, others
Public Health
Families
Research
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Classic Disease 45 year old woman; celebrating New Years day with
friends, “getting the flu”
Jan 2/3: Co-worker called, “Bad flu, staying in bed”. Declined Urgent Care
Jan 4: Did not show up at work; found moribund in home (in disarray and unlocked); “Drano” open next to body, spilled; Empty Theraflu and acetaminophen bottle; police reports of domestic assault in past; ? Fall / cut on face
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Clinical Presentation
BUN: 59 (Critical, high)
CO2 8.8 (critical, low)
Creatinine 2
Mg 3.5
Albumin 0.9
AST 564
Total Protein 2.8
ALT 125
Troponin I 11.92
CPK 12,939
CKMB: 372.7
B- natriuretic peptide: 1790
ABG: pH: 7.04
pCO2 36 (normal)
pO2 (100%, ambu) 59
HCO3: 9.7
Electrolytes, Glucose, bilirubin, Alk Phos, CBC: Normal Normal EKG Glasgow Score: 6 Expired < 45 minutes after admission
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Acute Bacterial Endocarditis
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Summary Staphococcus aureus acute bacterial endocarditis and
sepsis, systemic seeding
Cultures positive
Positive blood cultures from ER (2/2)
Culture + from valve vegetations at autopsy (within few hours of autopsy)
Closure of police investigation promptly
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Families – Case 1: Spry, widowed farmer in nineties
Wanted to stay independently living on family homestead farm
Decreasing driving ability
Family agreed to his continued driving with conditions
Only drove in daylight
Only drove in his rural community
Promised to always wear seatbelt
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Death Investigation Car ran off county road
Catches fire in overgrown field
Body extensively charred Dental ID Confirmed
Seatbelt burned but latched
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Autopsy Findings Massive pontine
hemorrhage
Died before car fire
No soot in airway
Negative CO levels
Died prior to traffic “accident”
No hemorrhage in body cavities, organs
Natural death while driving a car
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Families: Case 2 48 year old male, dx with cirrhosis
Freely admitted to binge drinking – told to stop
Cut back to “couple of beers” on weekend; red wine with meals, 1-2 x week
Over next 6 – 12 months, developed shortness of breath, congestive heart failure – “Alcoholic cardiomyopathy”
“Pre-diabetes”; mild elevation of random blood glucose
Stop drinking
Lose weight
Exercise 12
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Death Investigation Found deceased in home
Cool, rigor, last seen 30 hours previously
In bed, night clothing undisturbed
Home neat, secure
One empty beer in bedroom where decedent found; additional beer in refrigerator.
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Death Investigation Considerations Potentially fatal natural disease present; irregular
medical care
Relatively young
No scene suspicions
History of ethanol abuse
Release to funeral home?
External exam and toxicology?
Autopsy?
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Liver: Cirrhosis with brown pigmentation Positive for Iron Deposits
Autopsy Findings
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Kidney Pancreas
Heart, (Prussian Blue)
Pancreas
Kidney, Prussian Blue Pancreas, Prussian Blue 16
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Hemochromatosis: NOT EtOH ! Systemic iron storage disease from altered Fe
metabolism
Genetic disease – passed down in families
Autosomal recessive; 10% carriers in US (Celtic, North European higher)
Incidence: 1/300 in US; 1:68 in Celtic origin
Clinical Presentation:
Appears mid life (40 – 50 males; 60 females) with total Fe > 20 grams
Symptoms: Cirrhosis, CHF, “bronze skin”, neurologic, diabetes – many mimicking EtOH Abuse
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Follow-up Family tested
One brother and sister with disease
Therapy initiated (Normal lifespan with Rx)
Role of ethanol
May increase severity and appear at early age
Red wine, more iron
Critical Family Health Importance
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Unexpected Answers 50 year old woman ran stop-light
T-bone collision; died at scene
Recent movement of temporary stop-light for road construction
Cat in car; cell phone on; cigarette lighter out
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The location of pineal gland may lead to critical compromises of vision if there is enlargement / tumor 20
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Possible consequences of pineal tumor Bi-temporal Visual
field defects
Compression on brain – inability / difficulty to elevate gaze
Other neurologic and visual consequences
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Case Conclusion Was it the cat, cell phone, cigarette
…..or brain tumor
….. or any of the reasons for traffic accidents??
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Public and Community Health New and emerging diseases
Product safety / workforce
safety
Infectious disease
Drug use changes and
patterns
Organ and tissue safety
Regional exposure and
disease
Chronic disease
Violence and trauma
Transportation / aviation
Suicide Vulnerable Populations
Domestic Violence
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Quality Review Middle aged woman, arrived in town with circus
Found deceased in trailer, drug paraphilia at scene
Two days prior, left at rest stop on interstate to seek medical attention
ER visit of vague abdominal pain, nausea, demanded several narcotics; constipated, no food for 2 days
Readily admitted to multiple drug use
Rehydrated and discharged as drug seeking addict
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Findings and Correlation Acute bronchopneumonia with empyema
Review of hospital records from ER visit 2 days prior, high normal range WBC, WITH BANDS AND LEFT SHIFT
Drug seeking addicts can develop pneumonia and other illnesses
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Undetected Disease Implications:
50 year old athlete found dead at home
Just returned from vacation in South Pacific 28 hour flight; severe leg cramps
Attempted workout on return, became short of breath Stopped, called Family Doc for appointment
Found dead ~ 1 hour later
Other minor risk factors Family history of sudden cardiac death
Cholesterol 205 four years prior, no treatment.
Smoked as teen; none in 30 years
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Assessment for Tissue Donation Pulmonary embolus presumed Cause of Death
Body released for pre-autopsy tissue donation; Corneal donation done
Tissue team arrived late in evening.
Question of hemodilution during resuscitation (Internal decision for second donation)
Deferred most tissue procurement
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Autopsy Findings Loose, pale clots, non-adherent, in some
pulmonary vessels and heart (believed post-mortem, section taken)
575 gm heart, no dilation or gross infarction
Up to 75% occlusion in coronary arteries
Intramyocardial LAD for 1 – 2 cm.
CNS: Edema, herniation, bilateral extrusion of hemorrhagic mass.
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Heart: Gross – Mild cardiomegaly (575gm); Bridging coronary artery and 75% ASCD
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Clot in large pulmonary vessels
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LEUKEMIA!
CBC: Leukemic overload – see large white cell population in tube settling
•(was actually the “dilution” seen by tissue procurement team)
Peripheral smear: Massive leukemic blast population Post mortem WBC: 729,000; (Normal 4 – 12)
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Larger Question Acute leukemia would be devastating if
used for transplantation.
How often is unsuspected cancer present at death?
“Forensic” vs. “Hospital” autopsies
If present, is it the cause of death?
Can safety of tissue and organ supply be improved with autopsy on donors?
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Five year study in Grand Forks (including 7 mts as ND State Forensic Examiner)
412 autopsies (exclude stillbirths and skeletons)
40 patients with cancer, 29 were unsuspected
Some patients with 2 different cancers
7% of Forensic cases had unsuspected Cancer
Caused death in 40%
16% of “medical” autopsies had unsuspected cancer
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Unsuspected Cancer and Tissue Deferral
0 10 20 30 40 50 60
None
Cancer Hx
Age
Behavior
Infection
None
Possible
Likely
DeferralReason
% Unsuspected Cancer Patients
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Types of Cancer / Neoplasia All Cancer seen at Autopsy
Pancr
eas
Lung
Ren
al
Prost
ate
GYN
Thyro
id
Hem
atop
oetic
Breas
t
Lary
nx/T
ongu
e
Ure
ter /
Pel
vis
Gal
lbla
dder
Stom
ach
Brain
0
2
4
6
8
10
12
14
Unsuspected, malignant
Clinical, discordant
Clinical, confirmed
Benign / Indeterminate
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Unsuspected cancer • Should autopsies be required on donors?
• Other advantages of autopsy • Family knowledge
• Medical care review
• Accuracy of death certification
• Accuracy of cancer risks, clusters
• Public health implication with cancer exposures, particularly in low-population areas
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Erionite Naturally occurring rock
Class 1 Carcinogen by IARC; Asbestos like compound
Present in ND; used as gravel in multiple uses (roads, playgrounds)
http://www.ndhealth.gov/EHS/erionite/
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Erionite High incidence mesothelioma in
Turkey with Erionite exposure
Strong genetic component (>50%)
Recent data 6% in non-risk families
Are ND residents at risk?
Levels higher than Turkish villages
Current mesothelioma is 1 -2 annually in ND
Are we missing 1 -2 or more a year?
http://www.ndhealth.gov/EHS/erionite/
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UND Commitment to ND Citizens Partner with ND INBRE and NDMA
Transportation Expenses for Funeral homes
Autopsy for any long term resident of affected area Consent for autopsy
Tissue for erionite and other fibrous burden (EPA)
Questionnaire for potential exposure and occupational history
Should answer question of latent disease
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Other Areas of Public Health and Law Elder abuse
Childhood deaths
Fire deaths
Cancer incidence and detection
Product safety issues
Farm and Agricultural Injury; other work injury/death
Infectious disease – Community risks
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National Picture in Forensic Sciences
Sweeping Changes in Forensic Sciences
DNA
CSI OJ
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Forensic Science in US National Academy of Sciences
2009 Report
Main themes
Accredited facilities
Certified personnel
Evidence based practice
Removal from law enforcement & judicial influence/ administrative structure
Research and Science in Forensic Practice / Activities
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National Direction NAS report: “Strengthening Forensic Science in US”
Accredited facilities: NAME accreditation - NO
Certified individuals: ABP in FP – 100%
Death Investigators: Now 5 in ND (ABMDI certified)
Increased evidence base
Independence of Investigations
Increasing research and knowledge advancement
Leahy bill – due for consideration in this session
Medical advancements / Forensic based research
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Past and Present in North Dakota Prior 1994: No Forensic Path base
1996 – 2006: Development
Recruitment of Dr. Mizell
Building of Office
Construction of new office
2007: Coroner legislation updated
Current:
Dr. Massello (all of ND)
Grand Forks County: Drs. Sens and Koponen
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North Dakota Forensic Autopsies
0
50
100
150
200
250
300
350
400
450
GF Coroner Autopsies
Bismarck Case Equivalent
Bismarck Autopsies
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Where we came from: UND Pathology Chair recruitment: 2000 – 2002, two searches: Education
and research, no clinical service Research base: Chair and 3 faculty
Two NIH grants; additional 2 shortly after arrival (~ 4M)
Continued grant development (INBRE 16M; STEER, AARA ~ 1.5M)
Education: Extensive med and grad school education base
Altru supportive of clinical practice on first visit Autopsy and forensic pathology ? Renal pathology / cardiac /
transplant pathology
Elected to provide autopsy and forensic pathology service – envisioned small % effort. ~ 20 to 25 autopsies (200 considered full time)
Desired involvement in Quality Assurance and Outcomes Research
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What happened
0
50
100
150
200
250
300
350
400
450
2002 2003 2004 2005 2006 2007 2008 2009 2010
SD
MN
Coroner
Bismarck
Autopsy
GOAL
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2004 – 2005: Redefining Goals Critical need for forensic services in
region To serve the citizens, families, hospitals and law enforcement
by establishing professional and nationally accredited death investigation
To provide excellence in forensic education and continuing education of students and professionals
To further an unwavering commitment to rural communities in service, access and education.
UND should target State needs for specialty Pathology faculty that complements, not competes, with hospitals Forensic, neuropathology, pediatric path, cardiac, renal, etc.
UND needs practice site capable of NAME accreditation and subspecialty needs
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UND Pathology (MD) Faculty
• Two current; more planned as expansion occurs
Forensic and Autopsy Pathology
• Planned recruitment +/- FP; NP referrals from entire state; research collaboration, eating disorders, neurodegenerative diseases; partner with ND hospitals / neurology/neurosurgery
Neuropathology
• Planned recruitment +/- FP, NP; referrals from region; research collaboration with developmental neuropath, eating disorders
Pediatric Pathology
• Not high income specialties to avoid hospital competition
Other Subspecialists
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National Standards in Forensic Medical Science Regional professional death investigation
systems
ABP Board Certified Forensic pathologists
ABMDI Certified Death Investigators
Accredited autopsy and office facilities
Evidence based practice, national guidelines
Research in forensic sciences
Applied research
Integration with “basic” research
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Medical Legal Death Investigators
• National shortage in Medical Examiner Offices
Key Personnel
• No degree program; OTJ trained
• Nursing, EMS, Forensic Science, Law Enforcement, Others
Background
• Week long training conferences ( 32 – 48 hours didactic)
• Mentorship/training during employment in home office
Training
• National exam (ABMDI) after field experience
Certification
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Current Medical Legal Death Investigator Training and Career
Excellent for large metropolitan systems
Allows wide breadth of applicants
National standards and certification for all
“Orphan” career without University base
Requires ME offices to assume large training duty
Totally inapplicable to rural and frontier systems
Only 110 of 3117 counties in US (3%) could realistically support current system
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Death Investigators Rural needs must be met:
Training at distant locations not practical
Certification requirements
No university / college curricula – professional gap
Career path and degree for current investigators
Training standards for all investigators
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Educational Opportunities NIJ competitive training award: Oct, 2010 (Active 5/11)
1 Million, 3 year grant for development of distance education, aimed at part-time, rural practitioners
Focus on training of these para-professionals, law enforcement, coroners in modern death investigation
Asynchronously delivered, standards based, on-line didactic training for death investigation
Four (4) On-site focused workshops, 100 participants each
Free to learners for grant development
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Components of Online Training Basics of Death Investigation
Utilizing current NIJ, ABDMI and NAME guidelines
Basic Forensic Pathology
Types of trauma and documentation
Basic Forensic Science
Overview of disciplines, i.e. arson, fingerprints, ballistics, trace evidence, blood splatter, etc.
What to recognize at scene
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Components of Online Training Case Studies: Integration of scene – crime lab
– autopsy – courts – family/medical follow-up
Cultural competencies and Next-of-kin services
Mental health in death investigation
Taking care of responders
“First Aid” for recognizing high risk situations; resources for involving professionals
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Strengths and Assets Strong cooperation with all agencies in state
People of North Dakota
Partnering potential is prime time
Excellent base of people and facilities
Base for translational studies and research opportunities with ND Universities, health systems
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Challenges Rural distances
Bismarck case load exceeds National Standards; precludes NAME accreditation
Training of death investigators
Work distribution
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Unique Opportunities for ND New Facility in Grand Forks County
Partnering with UND for provision of services
Training for rural investigators
Increased use of telemedicine, IT resources
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New Facility in Grand Forks
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UND Facility (Open late 2010; 7200 sq. feet)
NAME Accreditation: Two autopsy rooms, two coolers, (regular and decomposition), storage, dedicated personnel, extensive security and protocols
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Dual, secure Coolers
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Coolers (warmer)
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Main Autopsy Room
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Specialized dissection area
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Triage area
Also: Secure garage Waiting area for drivers Conference room “Smoking” room Large, secure evidence / property room Secure records room Additional specialized autopsy room Ease for students / trainees Wired / place for LODOX scanner
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Future Sentinel time in North Dakota history for integration
of forensic services
People and facilities largely in place
Increased opportunity through cooperation across agencies in State.
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