investigation using forensic pathology beyond the autopsy
TRANSCRIPT
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PreventingErrorsinDeathInvestigation
usingForensicPathologyBeyondthe
Autopsy
ElizabethA.Laposata,MD,FCAP,FASCPForensicPathology&LegalMedicine,Inc.
Providence,[email protected]
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ElizabethA.Laposata,MD,FCAP,FASCP
• DiplomateoftheAmericanBoardofPathology– Anatomic&ForensicPathology
• Over35yearsexperience– AssistantmedicalexaminerinSt.Louis,Delaware,Philadelphia
– ChiefMedicalExaminerStateofRhodeIsland– President,ForensicPathology&LegalMedicineanindependentmedicolegalconsultingpractice
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Beyondtheautopsy
• Analyzingallforensicevidenceandfactsofthecase– DNA– Traceevidence– Ballistics– Toolmarks– Fingerprints– Surveillancevideo– Crimescenereportsandphotographs– Autopsy
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Medicalexaminer’soffice
• Autopsydonetoprofessionalstandards– PhotographsandX-Rays–Medicalinterventions– Histology– Toxicology
• Medicalhistory• Scenephotographs• Witnessstatements
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Pathologyexpert
• Autopsydonebyqualified,experienceddoctorwithlicensetopracticemedicineandboardcertifiedinforensicpathology
• “Weseeonlywhatweknow.”-JohannWolfgangGoethe
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Sixquestionstobeansweredfromexaminationofthebody
1. Whoisthevictim?2. Whendidthedeathand/orinjuriesoccur?3. Wherewasthescene;whatwerethe
circumstances?4. Whatinjuriesarepresent?5. Whichinjuriesaresignificant?6. Why&howweretheinjuriesproduced?
From:AdelsonL(1974)PathologyofHomicideCharlesC.Thomas; Springfield,IL
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Beyondtheautopsy
• Usetheforensicpathologist’straininginclinicalmedicinediagnosistoanalysisallthefactsofthedeathinvestigationusing
– Inferentialthinkingorreasoningtodevelopadifferentialdiagnosis
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Usingamedicalmodeltopreventerrorsindeathinvestigation
• Whydodoctorsinclinicalmedicinemakemistakes?
• Answer:deductivereasoning
• Whatdotheydoaboutit?
• Answer:inferentialreasoning
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Deductivereasoning(nodifferentialdiagnosis)
• Top-downlogicgivenafactorfinding
• Aconclusionbasedonafundamentaldictumknowntobetrue
Finding
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Deductive:top-downlogic
• Patientswithinfectionhavehighwhitebloodcellcounts
• MypatienthasahighWBCcount
• Diagnosis:Mypatienthasaninfection– Startantibiotics;cultureblood,urine,cerebrospinalfluid;placeinisolation
FINDING
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Inductivereasoning(createsadifferentialdiagnosis)
• Bottom-uplogic• Generatesalistofpossiblewaysacertainoutcomecouldhavebeenproduced
Inductivereasoninggeneratesideas
Finding
Ideasastopossiblecauses
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Inductivereasoning:bottom-uplogic
• Createadifferentialdiagnoses
• HowmanywayscouldmypatientdevelopahighWBC?
• MypatienthasahighWBCcount
infection leukemia drugreaction autoimmunedisease acutestressreaction
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Case1:childwithabdominaltrauma
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Casesensitivematerialomittedfordistribution
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Case2:ManwithStabWounds
Casesensitivematerialomittedfordistribution
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Case3:DeathAfterFightwithPolice
Casesensitivematerialomittedfordistribution
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Case4:NakedWomanDeadonGroundOutsideHouse
Casesensitivematerialomittedfordistribution
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BarrierstoInductiveReasoning
• Groupthink• Bias• Silos• Prematureclosure• “Wicked”problems
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Workwiththeforensicpathologistatthebeginningofthecase
• Dismantlesilosandshareinformation
• Developalistofdifferentialdiagnosesbyusinginductivereasoning
• Utilizetargetedtestingtogetanswersthatareprobative
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CasesforInformationSharingandInferentialReasoning:
Howelsecouldithaveoccurred?
• Triage– Highprofilecases• Deathsofchildrenandinfants• Deathsincustody• Deathsofindividualsofpublicinterest
– Complexcaseswithmultipledatapointsortypesofevidence
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